PARTNERS - IIX Foundation...Low-income and rural women, in particular, are disproportionately...

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Thispublicationmaybereproducedinwholeor inpartforeducationalornon-profitpurposeswithoutspecial permission from the copyright holder, provided that the source is acknowledged. ImpactInvestment Exchange (IIX) would appreciate receiving a copy of any publication that uses thispublicationasasource.

No use may be made of this publication for resale or any other commercial purposes whatsoeverwithoutpriorpermission,withastatementofpurposeandextentofreproduction,shouldbeaddressedtoDurreenShahnaz,founderandCEOofIIX.


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PARTNERS

ThisreportwasdevelopedbyImpactInvestmentExchange(IIX)AsiaPte.Ltd.andfundedbyMedtronicFoundation.

IMPACTINVESTMENTEXCHANGE(IIX)

IIXisaglobalorganizationdedicatedtobuildingamoreinclusiveworldasthefoundationforsustainablepeace.Wedothisbychangingfinancialsystemsandinnovatingsolutionsforwomenempowerment,climateaction,andcommunityresilience.Overthepastdecade,wehavebuilttheworld’slargestcrowdfundingplatformforimpactinvesting(ImpactPartners),createdinnovative

financialproductssuchastheWomen'sLivelihoodBond,operatedaward-winningenterprisetechnicalassistanceprogramssuchasIIXACTS,andestablishedanImpactInstitutefortrainingandeducation.Todate,ourworkhasspanned40countries,unlockednearly$75millionofprivatesectorcapital,avoidedover850,000tonnesofcarbonandimpactedover23millionlives.IIXhasreceivednumerousawardsfor

itsworkincludingtheOsloBusinessforPeaceAward,the‘NobelPrizeforBusiness.’

TheMedtronicFoundationisfocusedonexpandingaccesstoqualitychronicdiseasecareamongunderservedpopulationsworldwide,aswellassupportinghealthinitiativesincommunitieswhere

Medtronicemployeesliveandgive.MedtronicFoundation’sphilanthropicworkistheembodimentoftheMedtronicMissiontoalleviatepain,restorehealthandextendlife.MedtronicFoundationis

committedtoaddressinghealthissuesfortheunderservedandrecognizethattodosoiscomplexandrequirespartnership.MedtronicFoundation’sworkisgroundedintheadvancementoftheGlobal

SustainableDevelopmentGoals(SDGs).MedtronicFoundationbelievesthatbytheworldcommunity–bothpublicandprivatesectors–pullingtogetherwecanmultiplyourcollectiveactionsandstrengths

towardsharedpursuitofglobalgood.MedtronicInc.isthesolefunderofMedtronicFoundation.


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TableofContentsLISTOFACRONYMS..............................................................................................................................5LISTOFTABLESANDFIGURES..............................................................................................................6EXECUTIVESUMMARY..........................................................................................................................7ACKNOWLEDGEMENTS........................................................................................................................9IIX’SWOMEN’SHEALTHPRINCIPLES..................................................................................................13METHODOLOGYTONARROWDOWNFOCUSAREASFORTHEWHB................................................16CRITERIA1:TARGETISSUEAREAS.......................................................................................................17CRITERIA2:TARGETSEGMENTOFTHEHEALTHCONTINUUM..........................................................26CRITERIA3:TARGETSTATES...............................................................................................................30BLUEPRINTOFTHEWOMEN’SHEALTHBOND..................................................................................38ILLUSTRATIVECASES..........................................................................................................................45WOMEN’SHEALTHIMPACTASSESSMENTTOOLKIT.........................................................................50CALLTOACTION.................................................................................................................................56REFERENCES.......................................................................................................................................57


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LISTOFACRONYMS

• AHRQ:AgencyforHealthcareResearchandQuality(AHRQ)

• ACA:AffordableCareAct

• ACS:AmericanCancerSociety

• CA:California

• CDC:CentreforDiseaseControlandPrevention(CDC)

• CMS:CentreforMedicareandMedicaid(CMS)

• FPL:FederalPovertyLevel

• GIIN:GlobalImpactInvestmentNetworks

• HEDIS:HealthcareEffectivenessDataandInformationSet

• HPV:HumanPapillomavirus

• MN:Minnesota

• NCQA:NationalCommitteeforQualityAssurance

• NY:NewYork

• NYP:NewYork-Presbyterian

• ICHOM:InternationalConsortiumofHealthOutcomesMeasurement

• IOM:InstituteofMedicine

• IRIS:ImpactReportingandInvestmentStandards

• IIX:ImpactInvestmentExchange

• UN:UnitedNations

• SDG:SustainableDevelopmentGoal(s)

• SDH:SocialDeterminantsofHealth

• US/USA:UnitedStatesofAmerica

• USAID:UnitedStatesAgencyforInternationalDevelopment

• WHB:Women’sHealthBond

• WHO:WorldHealthOrganization

• WOC:WomenofColor


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LISTOFTABLESANDFIGURESTABLESTABLE1:LISTOFINTERVIEWEES……………….……………………….……………………….………….…………….10TABLE 2: KEY CHALLENGES AND UNDERFUNDED AREAS FACED BY UNDERSERVEDWOMEN INTERMSOFCANCERPREVENTION,EARLYDETECTIONANDTREATMENT……………….…………………18TABLE3:COMPARINGBREASTANDCERVICALCANCERFUNDINGBASEDONACSGRANTS……….20TABLE4:CERVICALCANCERINCIDENCEANDMORTALITYRATEACROSSETHNICGROUPS…….….20TABLE 5: KEY CHALLENGES AND UNDERFUNDED AREAS FACED BY UNDERSERVEDWOMEN INTERMSOFAFFORDABILITYANDQUALITYOFMATERNALHEALTH……………………………….……….…21TABLE6:POSITIVESCREENINGCRITERIAFORTARGETSTATES….…………….………………….…………..33TABLE7:ABSOLUTENEED–SUMMARYOFKEYSTATISTICS….…………….………………………………..…34TABLE8:ACUITYNEED–SUMMARYOFKEYSTATISTICS….……………………………………………………..35TABLE9:COMPARITIVEANALYSISOFPOTENTIALBONDSTRUCTURES…….…………….……………….44FIGURESFIGURE1:PATIENT-CENTEREDECOSYSTEMMAPPINGFOCUSEDONWOMEN…………………………..10FIGURE2:FACTORSINCLUDEDINDETERMININGPATIENT-CENTEREDCARE…………………………….14FIGURE3:METHODOLOGYOVERVIEWANDALIGNMENTWITHWOMEN’SHEALTHPRINCIPLES….16FIGURE4:WHBFOCUSONWOMEN-SPECIFICCANCERS…….…………….……………………………………..17FIGURE5:FIVEYEARESTIMATESOFBREASTCANCERMORTALITYRATES…………………………….….19FIGURE6:WHBFOCUSONMATERNALHEALTHANDREPRODUCTIVERIGHTS………………………….21FIGURE7:PREVENTABILTYOFMATERNALMORTALITYBASEDONTIMEOFDEATHINRELATIONTOPREGNANCY……..……….………………………….…………….………………………….…………….……………….23FIGURE8:LEADINGUNDERLYINGCAUSEOFPREGNANCY-RELATEDDEATHS,BYRACE/ETHINICITY..….…………….………………………….…………….………………………….…………….………….24FIGURE9:DISPARITIESINCONTRACEPTIONUSEANDABORTIONACCESS……………………………….25FIGURE10:QUANTIFYINGCONTRACEPTIVEUSEBASEDONRACEANDETHNICITY……………………25FIGURE11:LEVELSOFHEALTHCARESYSTEMANDCONTINUUMOFCARE……………………………….26FIGURE12:RIPPLEEFFECTOFREACTIVEHEALTHCARE…….…………….………………………………………27FIGURE13:DISTRIBUTIONOFPREVENTABILITYAMONGPREGNANCYRELATEDDEATHS…………..28FIGURE14:WHBAPPROACHTOEMBRACEPROACTIVECAREACROSSTHECONTINUUM…………..29FIGURE15:EXPLORINGTHEINTERESTININVESTINGINWOMEN’SHEALTH–THEINTERSECTIONOFTHEINNOVATIVEFINANCEANDGENDER-LENSMOVEMENTS…….…………….………………………..31FIGURE16:TAPPINGINTOTHEIMPACTINVESTINGMOVEMENTTOFINANCEHEALTHCARE……..32FIGURE17:ESTIMATEDUNDOCUMENTEDPOPULATION(2014)….….…………….………………………….36FIGURE18:ESTIMATEDNUMBEROFWOMENWHOAREUNINSURED(2014)…….…………….…………36FIGURE19:MAPPINGUNINTENDEDPREGNANCYRATEPER1000WOMEN,15–44…………………….37FIGURE20:DESIGNINGTHEBLUEPRINTOFTHEBOND……………………………………………………………39FIGURE21:OUTLINEOFSUSTAINABILITYBONDMECHANISM…………………………………………………40Figure22:OUTLINEOFSOCIALIMPACTBONDS………………………………………………………………………41Figure23:OUTLINEOFTHEHUMANITYBOND………………………………………………………………………..42FIGURE24:OUTLINEOFGAVIBONDMECHANISM…………………………………………………………………..43FIGURE25:5-YEARROADMAPFORWOMEN’SHEALTHBONDSERIES……………………………………….45FIGURE26:ILLUSTRATIVEEXAMPLEOFTHEWOMEN’SHEALTHBONDFORACS………………..…….47FIGURE27:ILLUSTRATIVEEXAMPLEOFTHEWOMEN’SHEALTHBONDFORTHEMOTHER’SCENTER………………………………………………………………………………………………………………………………49Figure28:IIXSUSTAINABILITYPYRAMIDTM…………………………………….……………………………………….51FIGURE29:KEYCHALLENGESINMEASURINGIMPACTTHROUGHTHELENSOFIMPROVINGHEALTHCAREFORUNDERSERVEDWOMEN….………………………………….……………………………………53FIGURE30:FIVESTAGEPROCESSOFMEASURINGIMPACT….…………………………………………………..53


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EXECUTIVESUMMARY

Women’sHealthMatters

IIXandIIXFoundationUSAbelievenowomenshouldbedeniedhealth access because of financial or social barriers. IIX hasspent thepastdecadeusing its expertise in innovative financeto empowermillions of underservedwomen across theworld.IIXandIIXFoundationUSAarenowbuildingonthismovementto bring underserved women in the United States to theforefront of financial markets through the Women’s HealthBond (WHB). TheWHB embraces IIX’smission to connect thebackstreetsofunderservedcommunitiestotheWallStreetsoftheworldbyensuringwomenhavebetteraccesstohealthcarethatisaffordable,inclusiveandpatient-centric.

This feasibility study report developed by Impact InvestmentExchange (IIX) is the first phase of designing an innovativefinancialmechanism,theWHB,basedonasystematicreviewofkey barriers to patient-centered health care, health needs ofwomen in the United States and investment drivers that canhelp scale up potential solutions. The report will lay thefoundation for the second phase of the work, which entailsdeveloping a series ofBonds that are equipped to unlock newsourcesofinvestmentcapitaltodriveforwardpatient-centeredoutcomes for underserved women in the United States. TheWHBseries isexpected tounlock$100millionovera five-yeartimeframewithagoaltoimpact2millionwomen.

Low-income and rural women, in particular, aredisproportionatelyimpactedbythelackofaccesstoaffordablehealthcare.Womentendtohavemorecontactwithhealthcaresystems, greater needs during childbearing years, and asprimarycaregiversmoreinterfacewithhealthcareprovidersonbehalfofothers.Thismakesitimperativetoensureallwomen,regardlessof their socio-economicbackground,haveaccess toquality health care. For the purposes of the feasibility study,underservedwomenincludeoneormoreofthefollowing:

• Womenlivingbelow200%oftheFederalPovertyLevel• Womenlivinginruralcommunities• Womenofcolor(WOC),ethnicminorities• Other women that are traditionally excluded from the

health care system (undocumented, uninsured, non-Englishspeaking,etc.)


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NavigatingtheReport:KeyFindingsandSectionOverviews

Keyfindingsfromthereporthavebeensummarizedbelow:

• IIX Principles for AdvancingWomen’s Health:Aspartof the feasibility study, the IIX teamhasconducted+40stakeholderinterviewsandanextensivefieldvisittolearnaboutkeychallengesonthe ground based on insights from industry experts, frontline health workers and patientsthemselves.ThisprocesshasledIIXtodevelopthreeguidingprinciplestoensuretheeffectivenessof theWomen’s Health Bond in creating a demonstrable positive impact on women’s health: (i)patient-centered–embracingsixcoredimensionsofhealth:access,affordability,equity,efficiency,qualityand responsiveness; (ii) proactive– redefining thenarrative from reactivehealth care thatsolelyfocusesontreatmenttoproactivehealthcarethatalsofocusesonprevention;and(iii)usingpositiveincentivestolinkimpacttocapitalmobilized.

• DefinedtheneedforaninnovativefinancialstructuresuchastheWHBandnarroweddownthefocus areas: TheWHBwill focus on women-specific cancers such as breast and cervical cancer,maternal health (prioritizing initiatives that also target mothers at risk of heart disease anddiabetes)andreproductiverights.TheWHBwillprioritizeinitiativesfocusedondeliveringproactivehealthcareviapreventionandearlydetectionorbyreducingdelaystotreatmentwiththeobjectiveto savemore lives today and reduce future outlays of costs to patients and providers. The threestates that IIXwill focuson for the initial tranchesof theBond includeCalifornia (CA),Minnesota(MN)andNewYork(NY).Thedecision-makingprocesstonarrowdownthefocusareasfortheWHBinitiativeisfurtheroutlinedinthe‘Methodology’sectionofthereport.

• AssessedthestructuresofthreedifferentinnovativefinancialmechanismsinthecontextoftheWHB: The IIX team has reviewed three potential structures for theWomen’s Health Bond, andbasedonfindingstodate,hasdeterminedthataHumanityBondstructurewillbethemostsuitable.Thestructureiswellsuitedtouseablendedfinanceapproachbyusingexistingconcessionalcapitalfrom the philanthropic or public sectors to unlock upfront funding from private sector investors.Upfrontfundingcanbeusedbynon-profitstomagnifyhealthcareoutcomesatagreaterpaceandscale by funding proactive and time-sensitive initiatives while also reducing long-term costsassociated with reactive health care. An overview of the Bond structures considered and anillustrativecaseoftheproposedmechanismisfurtheroutlinedinthereport.

• NeedformeasurementandtheIAtoolkit:Thefieldvisitswerealsousedtoassesscurrentgapsinthemeasurementofhealthcareoutcomes,whichrevealedaseverelackofpatients’voicesinwhatgetsmeasuredandadisproportionatefocusonvolumeofcare(oroutputs)insteadofvalueofcare(oroutcomes).Toaddressthis,IIXhasalsodevelopedaWomen’sHealthImpactAssessmentToolkitdesignedtocomplementtheBond.TheWomen’sHealthImpactAssessmentToolkithasbeenbuiltbasedonIIX’s+9yeartrackrecordofconducting+130impactassessmentsacrosstheworldusingitsproprietary framework – the IIX Sustainability PyramidTM. The Toolkit is outlined in brief in thereportandfurtherdetailedinaseparateguidelinedocumentandspreadsheetthatwillbepublishedalongwiththisreport.


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ACKNOWLEDGEMENTS

IIXandMedtronicFoundation

This publication was prepared under the overall direction and guidance of Prof. Durreen Shahnaz,FounderandCEOof Impact InvestmentExchange (IIX) and IIXFoundationUSA.Colleagues from theMedtronicandMedtronicFoundationprovidedvalue input, includingOmar Ishrak,CEOofMedtronic,PaurviBhatt,PresidentofMedtronicFoundationandAnneKatherineWales,MedtronicFoundation.

Women’sHealthBondTaskForce

TheWomen’s Health Bond Task Force is comprised of a distinguished group of health care industryleaders, impact investing sector, corporations, philanthropic organizations, policymakers, and otherorganizationswithacommongoaltocreatehealthcareequalityforwomenintheUnitedStates.Themissionofthisuniquegroupofhigh-levelexpertswithon-the-groundexperienceandperspectivesistoinformandstrengthentheWomen’sHealthBondInitiativeledbyImpactInvestmentExchange(IIX)andsupportedbytheMedtronicFoundation.MembersoftheWomen’sHealthBondTaskForceinclude:

HealthcareExperts

Ms.ElanaAbraham-CorporateTreasurer,TheMountSinaiHealthSystemMr.OmarIshrak–CEO,MedtronicMs.KrisKim-ExecutiveVicePresident,NortheastRegion,AmericanCancerSocietyMs. Mary Manning - Division Director Health Promotion/Chronic Disease, Minnesota Department ofHealthDr.RuthSaber-Founder,TaraHealthFoundationMs.AstaSorensen-SocialScientist,RTIInternationalMs.JeanLimTerra-StrategicAdvisor,CorporateAffairs,GileadSciencesMs.PamelaZeller–President,ZellerSolutionsFinance/ImpactInvestingExperts

Mr.AntonyBugg-Levine-CEO,Non-ProfitFinanceFundMs.CynthiaCalderon-ManagingDirector,SmallWorldGroupIncubatorMr.PaulTregidgo-AdvisoryCouncil,CentreforFinancialInclusionAcademia

Prof.PaulBrest,DirectoroftheLawandPolicyLab,StanfordUniversityProf.CatherineClark-FacultyDirector,CenterfortheAdvancementofSocialEntrepreneurship(CASE),DukeUniversity’sFuquaSchoolofBusinessProf.KatherineKlein-ViceDean,WhartonSocialImpactInitiative,UniversityofPennsylvaniaStrategicPartnerships

Mr.GeorgeGreen-Founder,PluribusCapitalManagementMr.EdwardHartman-Co-Founder,LegalZoomMs.KalpanaRaina-ManagingPartner,252Solutions,LLCMr.AlanSeem-CorporateLawPartner, JonesDay;MemberofBoardofTrusteeofCaliforniaPacificMedicalCenterFoundation


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Ms.SharmilaMonaSinha-Trustee,SmithCollegeMr.JoesphYurcik-COO&CFO,TheaterMania.com

Interviewees

As part of the feasibility study, IIX interviewed + 40 health care experts and industry leaders ininnovativefinance,maternalhealth,reproductivehealthandwomen-specificcancers.Figure1outlinestheecosystemmappingcreatedby IIX, takingapatient-centeredapproachthatplacedwomenatthecenterofthehealthcareequation.Table1providesalistofintervieweeswhocontributedvaluableinputtothefeasibilitystudy:

FIGURE1:PATIENT-CENTEREDECOSYSTEMMAPPINGFOCUSEDONWOMEN

TABLE1:LISTOFINTERVIEWEES

Individual(s) Organization

JanetteFlint,ExecutiveDirectorNourbeseFlint,PolicyDirector

BlackWomenforWellness

LaceyClarke,DirectorofPolicyCommunityHealthCareAssociationofNewYorkState

JulieHammerman,BoardInvestmentCommitteeJulieRabinovitz,PresidentandCEO

EssentialHealthAccess

SarahVerbiest,DirectorTheNationalPreconceptionHealthandHealthCareInitiative

DianaRamos,MedicalDirectorforReproductiveHealthRitaSinghal,MedicalDirector(former)

LosAngelesCountyDepartmentofPublicHealth

JanMalcolm,CommissionerMaryManning,DivisionDirectorJoanBrandt,DivisionDirectorSusanCastellano,MaternalandChildHealthDirector

MinnesotaDepartmentofHealth

Women

Individual Non-profit For-profit For-Profit/NonProfit Government

MedicalSpecialists

Navigators

HomeCareProviders

PrimaryCareProviders

RuralClinics

Hospitals

CriticalAccessHospitals

ResearchInstitutions

PharmaceuticalCompanies

Foundations

Advocates

Medical&ProfessionalAssociations

CommunityBasedOrganizations

InsuranceAgenciesAuditors

Note: Many organizations, particularly enablers, playmultipleroleswithinthehealthcareecosystem.

MedicalDeviceProviders

Women-CentricApproachtoEcosystemMappingForthepurposeoftheWHB,womenarepositionedatthecenteroftheecosystemmapping.Inparticular,theWHBfocusesonunderservedwomen.ThisapproachisinlinewithIIX’smissiontotakeapatient-centered,gender-lensapproachtodevelopingtheWHB.

FrontlineHealthWorkersIndividualsdirectlyinteractingwithpatientstoprovideortofacilitatehealthcare.

EnablersOrganizationthatequipthehealthcaresystemtooperatebyprovidingfinancing,accesstoinformation,skillsdevelopmentservices,medicalsuppliesandequipment,etc.

HealthCareProvidersOrganizationsandinstitutionsthatprovidehealthcare.Thesecanrangefromlarge,usuallyurban,hospitalstosmallruralclinics.

RegulatorsActorsinchargeofestablishingtheguidelinesforhowandwhenhealthcareisprovided,andthosewhomonitorcompliancewiththoseguidelines.Thisgroupincludeslocal,stateandfederallevelpolicymakersaswell.

DESCRIPTION

Legislatures(Local/State/National)

FederallyQualified

HealthClinics

FinancialInstitutions

Agencies&Departments

(Local/State/National)

HealthcareSystems


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JanetOlstad,AssistantDirector

AvivaGoldstein,DirectorofDevelopmentDeborahKaplan,AssistantCommissioner

NewYorkCityDepartmentofHealth

MarilynKacica,MedicalDirectorKristineMesler,AssociateBureauDirectorWendyShaw,AssociateDirectorLaurenTobias,Director

NewYorkStateDepartmentofHealth,DivisionofFamilyHealth,ChildandAdolescentHealth

KarenPaolinelli,President CaliforniaAssociationofRuralHealthClinics

RickPotter,ExecutiveVicePresidentandCOO HealthServicesAdvisoryGroup

ClareBradley,SeniorVicePresidentandCMOTheodoreWill,CEO

IPRO

LeslieMcGowan,CEO LivingstonCommunityHealthCenter

SusanBradley,PresidentandCEOJuliaHejl,DirectorofDevelopmentAndreaLeti,ChiefDevelopmentOfficerLindaPahl,CFOJorgeTapia,DevelopmentAssociateBessWalkes,VicePresidentofDevelopment

PlannedParenthoodLACounty

GloriaMartinez,ChiefofStaff PlannedParenthoodNorthernCalifornia

EricStockton,HealthProgramManager,CommunityInvestmentMollyTheobald,Director,CommunityInvestment

AppalachianRegionalCommission

RachelWick,SeniorProgramOfficer BlueShieldofCaliforniaFoundation

CarlinaHansen,SeniorProgramOfficer CaliforniaHealthCareFoundation

TammyJohnson,SeniorDonorRelationsOfficerRosemaryVeniegas,SeniorProgramOfficer,Health

CaliforniaCommunityFoundation

SarojSedalia,Advisor–RabinMartin MerckforMothers

SommerBazuro,BoardMemberSusanJacobson,ManagerofBusinessandCommunityDevelopmentLindaTantawi,CEOKomenFoundation,GreaterNYC

SusanKomenFoundation

DeannaLarson,CEO AveraeCare

MichaelChinnavaso,CampaignDirector,CancerCenterKarenJeu,PresidentCeciliaThomas,Manager,CommunityHealthPrograms

CaliforniaPacificMedicalCenterFoundationandSutterHealth

ElanaAbraham,DirectorofSpecialProjects,Finance Mt.Sinai

AndresNieto,Director,CommunityHealthOutreach&MarketingVictoriaSchlegel,DirectorofCorporateandFoundationRelationsKarenSchmitt,ExecutiveDirector

NewYorkPresbyterian


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KariVredenburg,BusinessDevelopment

BrittanyPampuch,MedtronicLabs Medtronic

DavidHiggins,HeadofImpactInvesting JohnsonandJohnson

BarbaraLevy,VicePresidentforHealthPolicyAmericanCollegeofObstetricsandGynecologists

DianaRamos,ACOGFellowAmericanCollegeofObstetricsandGynecologists,California

AlisonTeitelbaum,ExecutiveDirector AmericanHealthQualityAssociation

KarenPaolinelli,President CaliforniaAssociationofRuralHealthClinics

LouiseMcCarthy,PresidentandCEO CommunityClinicAssociationofLACounty

KrisKim,ExecutiveVicePresident AmericanCancerSociety

ShobhaKrishnan,PresidentandFounderGlobalInitiativeAgainstHPVandCervicalCancer

PatriciaHeinrich,ExecutiveDirectorEmmaSmizik,AssociateProjectDirector

NationalInstituteforChildren'sHealthQuality

ChristineMorton,ProgramManager CaliforniaMaternalQualityCareCollaborative

HopeYates,DirectorofStrategyandCommunications ColombiaUniversity'sDepartmentofOB/GYN

AlinaSalganicoff,VicePresidentandDirectorofWomen’sHealthPolicy

KaiserFoundation

PeterSchafer,DirectorNewYorkAcademyofMedicine,CenterforHealthPolicyandPrograms

JenniferGriffin,ResearchEpidemiologist RTIInternational,CenterforGlobalHealth

MichaelTrisolini,SeniorDirectorRTIInternational,HealthCareQualityandOutcomesProgram

SamanthaSommerness,ClinicalAssistantProfessor UniversityofMinnesota,SchoolofNursing


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IIX’SWOMEN’SHEALTHPRINCIPLES

ThepurposeofthissectionistodefinethethreeprinciplesthatguidedthedevelopmentofthisreportandtheImpactAssessmenttoolkit:(i)PatientCentered;(ii)Proactive;and(iii)PositiveIncentives.

Principle1:Patient-CenteredCare

DefiningPatient-CenteredCare:Forthepurposesofthisreport,patient-centeredcarewillrefertotheInstitute of Medicine definition: ‘Providing care that is respectful of and responsive to patientpreferences, needs and values, ensuring patient values guide all clinical decisions’i. The objective oftaking a patient-centered approach is to improve trust, experience and outcomes of underservedwomenimpactedandtoenhancethequalityofthehealthsystem.

Why: There is a need to have patients at the center of the health care solution design process.Particularly,thevoicesofunderservedwomenaretypicallynotreflectedinhowhealthcareisdeliveredorhow‘success’or‘progress’getsmeasured.Assuch,themajorityofhealthsolutionsorinterventionstendtofocusonaccessibility,mortalityorcoveragewithlimitedconsiderationofdeeperelementssuchas health equity, patient satisfaction, ability to pay and other factorswherein social determinants ofhealtharetakenintoconsideration.

What:IIXhasusedtheframeworkoutlinedinFigure2toadoptpatient-centeredapproachbothinthedesign of theWHB and in the development of theWomen’sHealth ImpactAssessment Toolkit. Thefollowingsectionoutlineseachofthesixcorefacetsofpatient-centeredcare:

FIGURE2:FACTORSINCLUDEDINDETERMININGPATIENT-CENTEREDCARE

• Access:Accessreferstoimprovedproximity(orgeographicavailability);improvedsystemcapacity(havingadequatestaffwithrequiredskills,havingadequateequipment);andimprovedconnectivity(provisionofconsistentservicesandwhomthepatienttrustsi.e.buildsapersonalrelation).

• Affordability: Affordability refers to improved ability to pay for health; improved coverage oralternativemeanstopayforhealthcare;andreducedproblemaggravationduetodelayedhealthcare.

• Efficiency: Efficiency refers to improved cost effectiveness or reduced wastage or resources,increased organizational productivity and increased use of technology or data to drive improvedoutcomesand/orbetterresourceuse.

RESPONSIVENESS EFFICIENCY

EQUITY

ACCESS

QUALITY AFFORDABILITY

PATIENTCENTERED

CARE


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• Equity: Equity refers to increased health equality or reduced discrimination based on race orethnicity; increasedautonomyorappropriatenessofcarebasedonpatient’spersonalandculturalpreferences;andincreasedpatientsatisfaction(feelingofbeingtreatedwithdignityandempathy).

• Quality:Improvedeffectivenessrelatedtoreducedmorbidity,reducedmortality,improvedqualityof life, improved functional status of patient, etc.; improved patient safety (through clinicalappropriateness and adequate adherence to best practice structures/processes); and improvededucation/awarenessofpatientsonhealthcarerisksandrights.

• Responsiveness:Improvedtimeliness/promptnessofcare,shiftfromreactivetoproactivecareandimprovedclinicaloutcomesduetopromptcare;increasedclarity,completenessandconfidentialityofcommunicationinaneasytounderstandandactionablemanner;andimprovedcoordinationofcare(includingbetterpatientnavigation).

Principle2:Proactive

Why:Underservedwomentendtobemorereactivewiththeirhealthcare,typicallyseekingtreatmentonlyaftertheissuehasadvanced.Reflectiveofthis,mosthealthcareinterventionsandmeasurementtoolsfocusmostlyontreatment.

What: IIXrecommendsshiftingtowardsamoreproactiveapproachofdesigningsolutions,measuringimprovementinoutcomesandallocatingcapitaltoscaleinterventionsby:

• Expanding thecapital, time,andother resourcesallocated towardsprevention,earlydetectionorreduceddelaysbetweendiagnosisandtreatment.

• Conducting regular impactmonitoringand reportingusinganadaptivemanagementapproach toholdhealthcareprovidersorenablersmoreaccountabletobothpatientsandfunders.

• Engagingpatients directly to validate thehealthoutcomes theyhave experienced, potentially bydigitalizingtheimpactassessmentdatacollectionandverificationprocess.

Principle3:PositiveIncentives

Why:Thereisaneedtorefocuscapitaldeployedonthevalueofcarecreated,notthevolumeofcaredelivered. Many funding programs use negative incentives to penalize different groups for non-performancesuchasbyreducingfinancialreturnsorcuttingofffuturefundingstreams.

What: IIX recommends using positive incentives to accelerate the pace and scale of high-impactsolutionsthatwillimprovehealthoutcomesforunderservedwomenby:

• Designing an innovative financialmechanism that rewards investors for supportingwomen’shealthandcreates‘additionality’byunlockingnewsourcesofcapitalthatwouldotherwisenothave been allocated for this purpose.Thiscould involve (i)usingablendedfinanceapproachofconcessionary funding fromphilanthropic or public sector actors to leverage in or de-risk privatesectorinvestments;or(ii)offeringprivatesectorinvestorsafinancialreturninadditiontothesocialreturnsgenerated.The‘Blueprint’sectionofthisreportoutlineshowtheWHBcanachievethis.

• Linking impact achieved with capital mobilized. IIX’s impact assessment toolkit marries thecreationoftangibleimpactonunderservedwomenwiththeWHB’sabilitytomobilizeandallocatecapitaleffectively.Bylinkingfundingtooutcomesinsteadofoutputs,IIXusespositiveincentivestoshift the focus from volume of care to value of care. The ‘Women’s Health Impact AssessmentToolkit’sectionofthisreportfurtherdetailshowtheWHBcanadoptthisapproach.


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METHODOLOGYTONARROWDOWNFOCUSAREASFORTHEWHBThepurposeof this section is tooutline thekeycriteriaused tonarrowdown the focusareas for theWHB. Given the complexity of the US health care system, IIX took amulti-dimensional approach tonarrowdownthefocusoftheWHBtospecificissues,segmentsofthehealthcarecontinuumandstates.EachcriterionisalignedwithoneoftheWomen’sHealthPrinciplesdescribedintheprevioussection.

FIGURE3:METHODOLOGYOVERVIEWANDALIGNMENTWITHWOMEN’SHEALTHPRINCIPLES

Criteria1–PotentialtoImpactUnderservedWomenusingaPatient-CenteredApproach:WhileIIXrecognizesthathealthequityisimportantforthecommunityasawhole,thepurposeoftheWomen’sHealth Bond is to mobilize capital to drive improved health outcomes for women in particular.Additionally, IIX focused on issues that required additional funding to shift towards providingunderservedwomenwithmore inclusive, patient-centered care. As such, IIX has narrowed down thefocus areas of the Bond towomen-specific cancers (breast and cervical cancer)maternal health andreproductivehealth.

Criteria 2 – Potential of Intervention to Create Effective Outcomes by Embracing a ProactiveApproach:While all initiatives will be assessed on a case-by-case basis for their potential to impactunderserved women, the WHB will prioritize initiatives that advance proactive health care, supportpreventativemeasures,advanceearlydetectionandreducetimetotreatment.Thekeyfocuswillbetosupportprogramsthatcanmagnifyimpactatthesamecostorachievethesameimpactatalowercostoverthelongrun.

Criteria 3 – Potential for an Innovative Financial Mechanism to Unlock Capital using PositiveIncentives:Aspartofthefeasibilitystudy,IIXidentifiedstatesthathadacombinationoftwofactors(i)demand for capital, i.e. presence of innovative health care providers with solutions that neededadditional capital at an increasedpaceand scale; and (ii) supplyof capital, i.e. ability tobring innewinvestors from the private sector into the health care equation based on key investment drivers. Assuch,IIXhasnarroweddownthetargetstatesoftheBondtoCalifornia,NewYorkandMinnesota.

The following section outlines each of these key criteria sequentially althoughmany sub-factorswere assessed in parallel andplayedan influencing roleon eachother in order todetermine thefinalsetofnarroweddownfocusareasinaholisticmanner.

KeyCriteria

1PotentialtoImpactUnderservedWomenusingaPatientCentered

Approach

1aWomenspecificissues

1bIssuesimpactingunderservedcommunities

2PotentialofInterventiontoCreateEffectiveOutcomesbyEmbracingaProactive

Approach

2aAbilitytosavemorelivestodaybyimprovingqualityandaccess

2bAbilitytolowerfutureoutlaysofcosttoimproveaffordability

3PotentialforanInnovativeFinancialMechanismtoUnlockCapitalusingPositive

Incentives

3aNeedandfeasibilityofmobilizingalternativesourcesofcapital

3bNeedandfeasibilitytoabsorbanddeploymission-drivencapital

TargetIssueArea1.MaternalHealth(prenatal/postpartumcareand

reproductivejustice)2.Women-SpecificCancers(cervicalcancerand

breastcancer)

TargetStates1.California(highnumberoflow-incomewomen)2.NewYork(highnumberoflow-incomewomen)

3.Minnesota(highdisparities)

TargetSegmentofHealthcareContinuum1.Prevention(low-incomewomentendtobemore

reactivewiththeirhealthcare)2.EarlyDetectionandReducedDelaystoTreatment(relativelylargefundinggaps)

NARROWEDDOWNFOCUSAREASOFTHEWOMEN’SHEALTHBOND

KEY CRITERIA ALIGNED WITHWOMEN’SHEALTHPRINCIPLES

SUB-FACTORSCONSIDERED


17

CRITERIA1:TARGETISSUEAREAS

OVERVIEWOFWOMEN-SPECIFICCANCERS

IIXfollowedatwo-prongedapproachtoassessingchallengesfacedbyunderservedwomenasitrelatesto access, affordability and quality of women-specific cancers: (i) primary data collected through in-person and remote interviews,meetings and field visits – an important step to understandpriorities,acuityof need, and to identifypotential projects that are addressing the issue andwork towards theinitial shortlist of initiatives; and (ii) secondary data collected through desktop research, reviews ofofficial publications and reports, with key insights validated or verified during the field visits. Assummarizedinthecontextsection,IIXiscurrentlyexploringtwokeyareasundercancerasoutlinedinFigure4:

FIGURE4:WHBFOCUSONWOMEN-SPECIFICCANCERS

WOMEN-SPECIFICCANCER:BREASTCANCERANDCERVICALCANCER

Cancer is the second leading causeofdeathofwomen in theUnitedStates, killingone in every fourwomen.iiResearchindicatesthatbreastcancerhasthehighestincidenceofcancersaffectingwomen.iiiAlthoughrelatively lessprevalent,cervicalcancer isanotherwomen-specificcancerthatwasexploredaspartofthefeasibilitystudy.While93%ofcervicalcancersare‘preventable’,ivthediseaseisnotbeingadequatelypreventedintheUnitedStates,particularlyamonglowincomeandruralcommunitieswhotypically have lower awareness of the broader benefits of the HPV vaccination and / or associateencouragingthevaccinationwithpromotingpromiscuity.

KEYCHALLENGESBASEDONSTAKEHOLDERINTERVIEWS

Basedonstakeholder interviewsconductedwith frontlinehealthexperts in the field,TableXoutlinesunderfundedareasthataddtochallengesfacedbyunderservedwomenthroughthe lensesofaccess,affordability,andqualityforbreastandcervicalcancer.

•  Vaccinationforcervicalcancer•  Earlydetectionandreduceddelaystotreatmentforbreastandcervicalcancer

Prevention EarlyDetection Treatment Recovery


18

TABLE2:KEYCHALLENGESANDUNDERFUNDEDAREASFACEDBYUNDERSERVEDWOMENINTERMSOFCANCERPREVENTION,EARLYDETECTIONANDTREATMENT

Cancers Prevention(CervicalCancer)

EarlyDetection(Breast/CervicalCancer)

Treatment(Breast/CervicalCancer)

Affordability Women18-26whoarenotinsuredarenotcoveredfortheHPVvaccine

Screening for both breastand cervical cancers arecovered by manyinsurance programs butcanstillbeoutofreachforuninsured women. TheCDC has implementedpublicly funding programsfor each state to coveralmostwomen, regardlessof insurance, but use oftheseprogramsbyeligiblepatientsislow,largelyduetoawarenessandaccess.

Co-payscanbeexpensive,and multiple doctors (andmultipleco-pays)areoftenrequired.Most advocates ornavigators,whohelpguidea patient through thepayment and treatmentsystems, are not coveredby insurance.This impactsthe affordability oftreatmentfortheprovider,who often choose to notoffertheseservices.

Cervical cancerprevention,andearlydetectionand treatment forbreastandcervicalcancer,requiremultipleprovidervisits.Thesetransportationcosts,aswellaschildcareneededduringthesevisits,arenotcovered.

Quality Quality barriers forprevention of cervicalcancerarenotsignificant.

Limited availability ofproviders that women arecomfortable with (femaledoctors, nurses of thesame ethnicity) candecrease patient qualityand exacerbate issues oftrust in the system,particularlyamongwomenofcolor.

Lack of coordination ontreatment, and lack ofpatientadvocatescanleadtosuboptimaltreatment.

Healthcare institutionsandproviders,particularlythosein rural communities, can suffer from a lack of trainingamong the care givers or a lack of the appropriatemedicalequipment.

Access Lack of awareness, fromboth theguardianandthepediatrician, that theHPVvaccine is covered byinsuranceforminors.

Conflicting information,among both patients andservice providers, aboutthe recommendedfrequency of screeningscanleadtolapsedvisits.

The system for care andinsurance can be overlyconfusing for patients, forthose with low literacy orwho speak English as asecondlanguage.

Scarcity of service providers and institutions, particularly in rural areas, mean thatwomencanbeprohibitivelyfarfromhealthcareservices


19

ADDITIONALINSIGHTSFROMSECONDARYRESEARCH

BREASTCANCER

MainBarriers toEarlyDetection:Thetotalcostofillnessforbreastcancerhasbeenestimatedtobe$3.8 billion, of which $1.8 billion represents medical care costs.vMammography can improve earlydetectionbyasmuchas15-35%andreducethecostoftreatmentsignificantly.viCostcanactasabarrierto53%oflow-incomewomenfromaccessingpreventiveorearlydiagnosticservicesandismoreacuteamonguninsuredgroups.viiIncomehasbeenobservedtobestronglyassociatedwithbreastcancercareandsurvivalintheU.S.IntheUSwomenwithprivatehealthinsurancearemorelikelytoreceivebettercare than those women with arguably less adequate coverage such as that provided through theMedicaidprogramsofmanystates,orthosewithnocoverage.

OtherSocialDeterminants:Althoughlow-incomeleveland/oralackofhealthinsuranceisusuallyoneof the key reasons for breast cancer screening disparities in the U.S., other factors play a role,particularly for underservedwomen.viiiEven amongwomen between 40-64with insurance, only 68%hadarecentmammogram.Otherbarrierstomammographyscreeningmayinclude:ix

• Lackofausualhealthcareprovider• Lackofarecommendationfromaprovidertogetmammographyscreening• Loweducationlevel• Lackofawarenessofbreastcancerrisksandscreeningmethods• Lackofchildcare• Lackofsickleaveorunabletomisswork• Fearofbadnewsorpainfromtheprocedure• MorerecentmigrationtotheU.S.(bornoutsidetheU.S./livingintheU.S.forlessthan10years)• Culturalandlanguagedifferences

Racialdisparities:Blackwomenaremorelikelytocontractbreastcancerandare43%morelikelytodiefromit;Figure5providesinsightsfromthreecitiesinthetargetstatesx:

FIGURE5:FIVEYEARESTIMATESOFBREASTCANCERMORTALITYRATES

CERVICALCANCER

Barriers to Prevention and Early Detection: Althoughbreast cancer is higher in incidence, it is stillmoresignificantly funded thancervical cancer.Breastcancer receives themost fundingpernewcase($2,956) and the most funding relative to each death ($13,452) than any other cancer.x To further

FIGURE32:FIVEYEARESTIMATESOFBREASTCANCERMORTALITYRATESLOSANGELES(1990–2014)

NEWYORK(1990–2014)

MINNEAPOLIS(1990–2014)


20

illustrate this, Table 3 compares American Cancer Society breast cancer grants with cervical cancergrantsxi:

TABLE3:COMPARINGBREASTANDCERVICALCANCERFUNDINGBASEDONACSGRANTS

CancerType NumberofGrants GrantAmounts

Breastcancer 162 $91,422,750

Cervicalcancer 22 $9,337,128

SocialDeterminantsandOther InfluencingFactors:Lessthan1/3oflow-incomewomengetregularpap smears.xiiWomen frommedically underserved populations aremore likely to be diagnosedwithlate-stagecervicalthatmighthavebeentreatedmoreeffectivelyorcuredifdiagnosedearlier.Financial,physical, and cultural beliefs are also barriers that prevent individuals or groups from obtainingpreventative care.xiii This is aggravated by the fact that the HPV vaccination is associated withencouraging promiscuity and there is, therefore, a cultural and ‘mind-set’ barrier that may preventyoungwomenfromcompletingthedosageseries.Additionally,youngmenaretypicallynottargetedbycervicalcancerawarenessoreducationcampaigns.

RacialDisparities:Thecervicalcancermortalityrateforblackwomenwas10.1per100,000.xivForwhitewomen, it is 4.7 per 100,000.xvHispanic/Latino women, however, have the highest cervical cancerincidencerate.WhitewomenlivinginAppalachiasufferadisproportionatelyhigherriskfordevelopingcervical cancer than other white women. Incidence and death rates for cervical cancer are shown inTable4xvi:

TABLE4:CERVICALCANCERINCIDENCEANDMORTALITYRATEACROSSETHNICGROUPS

Racial/EthnicGroup IncidenceRate MortalityRate

AfricanAmerican 11.4 4.9

Asian/PacificIslander 8.0 2.4

Hispanic/Latino 13.8 3.3

White 8.5 2.3

Statisticsarefor2000-2004,age-adjustedtothe2000U.S.standardmillionpopulation,andrepresentthenumberofnewcasesofinvasivecancer(1)anddeaths(2)peryearper100,000women.


21

OVERVIEWOFMATERNALHEALTHANDREPRODUCTIVERIGHTS

The Women’s Health Bond will prioritize maternal health care in recognition that the ability forunderservedwomentomanagetheir fertilityaswellas thehealthof themselvesandtheirbabies isabasichumanright.IIXfollowedatwo-prongedapproachtoassessingchallengesfacedbyunderservedwomen as it relates to access, affordability and quality of maternal care: (i) primary data collectedthrough in-personandremote interviews,meetingsandfieldvisits–an importantsteptounderstandpriorities,acuityofneed,toidentifypotentialprojectsthatareaddressingtheissueandworktowardstheinitialshortlistofinitiatives;and(ii)secondarydatacollectedthroughdesktopresearch,reviewsofofficial publications and reports, with key insights validated or verified during the field visits. Assummarizedinthecontextsection,IIXiscurrentlyexploringtwokeyareasundermaternalhealth:

FIGURE6:WHBFOCUSONMATERNALHEALTHANDREPRODUCTIVERIGHTS

KEYCHALLENGESBASEDONSTAKEHOLDERINTERVIEWS

Basedon stakeholder interviewsconductedwith frontlinehealthexperts in the field,Table5outlinesunderfunded areas that add to challenges faced by underserved women through the lenses ofaffordabilityandqualityformaternalhealth.

TABLE5:KEYCHALLENGESANDUNDERFUNDEDAREASFACEDBYUNDERSERVEDWOMENINTERMSOFAFFORDABILITYANDQUALITYOFMATERNALHEALTH

MaternalHealth andReproductiveRights

Prevention EarlyDetection Treatment

Affordability - TitleX fundingprovidedfunding for familyplanning services for lowincome women (andmen), primarily throughPlanned Parenthood. Thisfunding is likely to be cutor eliminated, impactingnearly 1millionwomen inCaliforniaalone.- Medicaid will cover

- Women below thepoverty line can struggleto cover co-pays that areusually required for pre-natal visits. Co-pays canrange from $20-$100,depending on the clinicand the insuranceprovider.Multiplevisits,asrecommended for pre-natal care, can mean

- Patient advocates,doulas,etc.arenotalwayscoveredbyinsurance- Follow up visits formothers may not becovered, nor may chronicconditions developedduring or exacerbated bypregnancy – the threebiggestissuescontributingto escalating maternal


•  Improvingqualityofprenatalandpostpartumcare•  Advancingreproductiverights


22

chronic conditions thatimpact fertility andmaternal health, butclinicians may not haveproper incentives in termsofreimbursementtoordertestsorprovidetreatmentacross specialties ortreatment needs with afocus on healthy plannedpregnancies.

significantco-paycosts.- Working women,particularlythoselivingfarfrom service providers,have an opportunity costfor pre-natal visits due tolost work. This loss ofincome, inaddition to thefees of the visits, maymake pre-natal visitsinaccessibleduetocost.

mortality include heartdisease, hypertension andhemorrhage.

Quality - Clinicians do not treatwomen of childbearingage with fertility andconceptioninmindLack of awareness ofimpact of chronicconditions (diabetes,hypertension, etc.) onfetaldevelopment- Reimbursement policies(as above) may impactscreening and treatmentprovidedoremphasized

- In ruralareas, theremaynotbetrainedclinicianstoaddress pre-natal needsand coordinate withtreatment for chronicconditions- Evenwhen clinicians areappropriatelytrained, lackofoperationalfundingcanlead to sub-par facilitiesand lack of appropriatemedicalequipment.

- More than 60% of U.S.hospitals perform fewerthan 1000 deliveries peryear. Lower volumehospitals have beenshown to have highermaternal and neonatalmorbidityandmortality.- Without an advocate,women/families may nothave adequateinformation tounderstanding options—there can be a lack ofcoordination betweenclinicians- Clinicians may not workwith women to addresspostpartumhealthneeds

Access - Maternal Health andFamily Planning (MHFP):most low-income womenreceive family planningand maternal healthservices through PlannedParenthood(0.8outof1.1million in California).Cancellation of Title Xfunding (“Affordability”)means that women willhave to seek other clinicsfortheseservices- There can be severestigma against familyplanning, so even incircumstances where thewomanmayhavephysical

-Over one third of lowincome and/orunderserved women donot see a doctor in thefirsttrimester-Lack of awareness ofimpact of behaviors andchronicconditionsonfetaldevelopment-Clinics that offer pre-natal services can bedifficult to find,particularlyinruralareas.

-Obstetric departments inrural hospitals are closingatanalarmingrate.Today,only46%ofruralhospitalshave been able to retainobstetrics services. Thiscanbefurtherexacerbatedforwomenlookingforcarewithin a particularinsurance system, or for aclinicthattreatsuninsuredpatients.-Both patients and careproviderscandemonstratealackofknowledgeontheneed for frequent andsustained post-partumcare.


23

access to reproductiveservices there may beculturalandsocialbarrierspreventingtheiraccess.- Pre-conception (PC): isdependent on awarenessand capability ofclinicians. This oftenrequires sustainedlifestyle changes for thepatient, which requirefrequent follow ups fromtheprovider.

- Navigating the “system” can be difficult—understandingprenatalvisits,laboranddelivery,optionsforcomplications,etc.Thisisparticularlytrueforwomenwith low literacy, or who speak English as a secondlanguage.- Transportation logistics (duration, distance, childcare,medical companion) are a significant barrier for pre-natal, labor and delivery, and post-partum access tocare.Evenifcostwerenotanissue,whichitoftenis,thephysicalbarriercanbeenoughtopreventapatientfromobtainingcare.

ADDITIONALINSIGHTSFROMSECONDARYRESEARCH

MATERNALHEALTH

TheUnitedStatessawa26.6% increase inmaternaldeathsfrom2000 to2014, according toa recentstudy published inObstetrics & Gynecology.xviiIn contrast, maternal mortality rates in other similarlydeveloped nationsdecreased dramatically during this same period.xviiiLack of adequate prenatal andpostpartumcarearecontributingfactorstotheriseinmortality.Motherswhodonotreceiveprenatalcarearethreetimesmorelikelytogivebirthtoalowweightbaby;theirbabyisfivetimesmorelikelytodie.xixCertainnewscastsclaimeverywomanwhodies inchildbirth in theU.S.,anestimated70morecomeclose.xxSocialdeterminantscanfurtheraffecttheoutcomeofprenatalorpost-partumcare.Forinstance,motherswho live in poverty are 3 timesmore likely to have depression than thosewhodonot.xxi

Additionally,between58%–66%(averaging60%)ofpregnancy-relateddeathsarepreventablebasedontimeofdeathinrelationtopregnancy(Figure7).xxiiFederalandstatefundingshowonly6%ofblockgrantsfor"maternalandchildhealth"actuallygotothehealthofmothers.xxiiiIntheU.S,somedoctorsenteringthegrowingspecialtyofmaternal-fetalmedicinewereabletocompletethattrainingwithouteverspendingtimeinalabor-deliveryunit.xxiv

FIGURE7:PREVENTABILTYOFMATERNALMORTALITYBASEDONTIMEOFDEATHINRELATIONTOPREGNANCY

FIGURE28:PREVENTABILITYOFDEATHBASEDONTIMEOFDEATHINRELATIONTOPREGNANCY1


24

Considerableracialdisparitiesinpregnancy-relatedmortalityexist.AccordingtotheCDC,during2011–2013,thepregnancy-relatedmortalityratioswerexxv:

• 12.7deathsper100,000livebirthsforwhitewomen.• 43.5deathsper100,000livebirthsforblackwomen.• 14.4deathsper100,000livebirthsforwomenofotherraces.

Thismeansblackwomenareatespeciallyhighrisk,beingthreetofourtimesmorelikelytodieduringpregnancyorchildbirththanwhitewomen.Causesofpregnancy-relateddeathdifferbyrace(Figure8),whichhighlightsuniqueopportunitiesforprevention.xxvi

FIGURE8:LEADINGUNDERLYINGCAUSEOFPREGNANCY-RELATEDDEATHS,BYRACE/ETHINICITY

REPRODUCTIVERIGHTS

Thecostofunintendedpregnancies:Almosthalf(45%or2.8million)ofallpregnanciesintheUnitedStates are unintended, with nearly 5% of reproductive-agewomen having an unintended pregnancyeachyear.xxviiThecostofunintendedpregnanciestotheUSeconomyisestimatedtobe$21billionperyear.xxviiiOnly26%ofwomen inneedofpublicly fundedcontraceptives receivetheseservices,.18%ofwomen at risk of unintended pregnancy use contraceptives inconsistently/ incorrectly, and 10% ofwomendonotusecontraception.xxix

RacialDisparities:Womenofcolor(particularlyblackorHispanicwomen)andundocumentedwomenaredisproportionatelyunlikelytousecontraceptivesduetothreereasons:(i)providerbias:withintheblack community many patients experience negative patient-provider experiences; (ii) trust incontraceptiveoptions:biascombinedwithahistoryofforcedsterilizationandcoercionfostersdistrustin the health care system specifically for women of color; (iii) immigration status: undocumentedimmigrantsmaynothaveaccess to the financial resources to access contraceptives, even thosewhohavegainedlegalstatusmustwaitfiveyearsbeforereceivingMedicaidcoverage.xxx

DisparitiesincontraceptionusearemappedoutbelowinFigure9andFigure10:

FIGURE27:LEADINGUNDERLYINGCAUSESOFPREGNANC-RELATEDDEATHS,BYRACE-ETHNICITY1


25

FIGURE9:DISPARITIESINCONTRACEPTIONUSEANDABORTIONACCESS

FIGURE10:QUANTIFYINGCONTRACEPTIVEUSEBASEDONRACEANDETHNICITY

RepercussionsofCutstoTitleXFunding:DefundingofTitleXwillmeanthelossofnearly$300Mforfamilyplanningandhealthscreening for4millionpeople,mostofwhomare low-income.xxxiBetween2006 and 2010, a total of 43 million women aged 15 to 44 years reported having received familyplanning or a related medical service in the past 12 months.xxxii Approximately half of the 18% ofwomenwho received such careat a clinicdid soat aTitleX–funded clinic.xxxiiiUseofTitleX clinics ismorecommonamongwomenwholiveinanonmetropolitanareaorareblack,Hispanic/Latina,belowthepovertylevel,oruninsured.xxxiv

FIGURE30:DISPARITIESINCONTRACEPTIONUSEANDABORTIONACCESS

FIGURE31:QUANTIFYINGCONTRACEPTIVEUSEBASEDONRACEANDETHNICITY1


26

CRITERIA2:TARGETSEGMENTOFTHEHEALTHCONTINUUM

The second criterion is to ensure that theWHB takes a proactive approach to delivering care and isequipped to improve efficiency or effectiveness across the continuum of care (Figure 20) at threedistinctlevels:

1. Patient Level (main priority): Improving access, affordability and quality of health care,enhancinginclusivenesstodrivehealthequityandtimelinessofcare

2. Provider Level: Improving outcomes achieved by shifting to patient-centered care, achievingsamelong-termoutcomesatreducedcost

3. SystemLevel:Improvingcost-efficiency,reducingpressureoncapacity,shiftingtovalue-basedcarefromvolume-basedcare

Figure 11 provides an overview of the continuum of care overlaid with the levels of the health caresystem:

FIGURE11:LEVELSOFHEALTHCARESYSTEMANDCONTINUUMOFCARE

Thefollowingsectionwillexplorehowinterventionscan:

1. Improve effectiveness:Theabilitytoachieveimprovedhealthcareoutcomesinasustainablemanner

2. Improve efficiency: The ability to achieve the same outcomes while reducing the resources(time,money,talent)requiredoverthelong-term

SocialDeterminantsofHealthandRepercussionsofReactiveHealthCare

ImpactofSocialDeterminantsofHealthonLow-Income,Minority,RuralandWomenofColor

Based on interviews with patient advocates and frontline health workers, a common trend thatemergedwasthatlow-income,minorityandruralwomenalltendtobemorereactivewiththeirhealthcare.Expertssuggestthisispartlyduetosocialdeterminantsofhealth(SDH)whicharedefinedastheconditionsinwhichpeopleareborn,grow,work,live,andage,andthewidersetofforcesandsystemsshaping the conditions of daily life (WHO). These forces and systems include economic policies andsystems, development agendas, social norms, social policies and political systems. Women living inpoverty, women with lower education levels, women that struggle to navigate the system due tolanguagebarrierstypicallyaremorereactivewiththeirhealthcare.Womenofcolor,regardlessoftheirsocio-economicstatus,tendtohavelowertrustinthesystemandtherebyavoidavailingofhealthcare

PatientLevel

ProviderLevel

SystemLevel


Leve

lsofH

ealth

careSystem

ContinuumofCare


27

services until the issue has progressed to an advanced stage. Finally, research shows costs can be abarrierforbothinsuredanduninsuredwomenxxxv:

• 52%ofuninsuredwomenand13%ofinsuredwomenpostponepreventativeservicesbecauseofcost

• 50%ofuninsuredwomenand13%of insuredwomenskiprecommendedmedicaltestsduetocosts.

RepercussionsofReactiveHealthCareAcrosstheSystem

The repercussions ofwomenbeing reactivewhen seeking health care have a ripple effect across thehealth care systemas outlinedbelow (Figure 12).As such, a reactive approach to health care canbebothexpensiveandsomewhatineffectiveatachievingsustainableoutcomes.

FIGURE12:RIPPLEEFFECTOFREACTIVEHEALTHCARE

ProactiveBreastandCervicalCancerMeasures:

• Cervical cancer: Vaccines are available to help prevent infection by certain types ofHPV andsome of the cancers linked to those types. As of 2017, Gardasil 9® is the only HPV vaccineavailableintheUnitedStates.Gardasil9helpspreventinfectionby4typesofHPV(16,18,6and11),plus5otherhighrisktypes:31,33,45,52and58.xxxviTogetherthesetypescauseabout90%ofcervicalcancers(aswellasmanyothercancersoftheanus,penis,vagina,vulvaandthroat).Anotherwell-provenway toprevent cervical cancer is tohave testing (screening) to findpre-cancers before they can turn into invasive cancer.xxxviiThe Pap test (or Pap smear) and thehumanpapillomavirus(HPV)testareusedforthis.

• Breastcancer:Preventionofbreastcancer ismostly linkedto lifestylechanges,healthierdietsand preventative surgery. Different tests can be used to detect breast cancer early includingmammograms,breastultrasounds,breastMRIscans,newerbreastimagingtestsandbiopsy.

AbilitytoEnhanceOutcomes:

While the cervical cancer vaccination has a proven ability to improve outcomes (by completelyeliminatingtheriskofmortality),earlydetectionofbreastcancer ismorecomplex.Data fromclinicaltrials ofmammography showed it reduces themortality rate from breast cancer by at least 15% forwomen in their 40s and by at least 20% for older women.xxxviiiHowever, it is important to note thatresearch indicatesthatwhile5 in1,000womendieofbreastcancerwithoutavailingofscreening, thenumberisonlyreducedby4in1,000womenforwomenwhoarescreened.xxxixThesocialandfinancialcostoffalsepositivesindicatesincreasedneedtoimprovequalityofscreeningtools.

PatientLevel

ProviderLevel

SystemLevel

Lowerprobabilityofsuccessfuloutcomesandreducedqualityoflife,higherlong-termcosts(treatmentistypicallymoreexpensivethanprevention)

Increasedpressureoncapacity,highercomplexityandresourceintensivenessofinterventionsrequiredtoachievethesameoutcomes

Higherpressureonthesystemduetolongerperiodsoftreatment,higherhealthcarecoststobeabsorbedatthestateandnationallevel


28

AbilitytoReduceLongTermCosts:

• Patientlevel:California,MinnesotaandNewYorkprovidefreebreast/cervicalcancerscreeningfortheuninsured/underinsured.However,thisrequireswomentobeeligible(low-incomestatusdependentonstateregulations).Italsorequireswomentobeawareoftheprogram,applyforeligibility, andbeable tonavigate/access theproviderand/or reimbursement systemwhich istypicallywhyallunderservedwomendonotbenefitfromtheseprograms.

• Provider/Systemlevel:Theannualnationalcostsavingsforearlydiagnosisofbreastcancerisestimatedtobe$1,562millionandforcervicalcancertobe$221million.xl

• Additionalconsiderations:Whilethemajorityoffundingisfocusedoncancertreatment,thereisrelativelylowerfundingavailableforpreventionandearlydetection.Forinstance,theNationalCancer Institutebudget for2012-13 reflected$1.3billion for treatmentversus$232million forprevention.xli

ProactiveMaternalHealthCareMeasures:

• Nearly60%ofpregnancy-relateddeathsareestimatedaspreventable(Figure13).xlii

• The two primary causes of death are cardiovascular disease and other medical non-cardiovascular disease, indicating potential issues related to prenatal health or preventabledisease.xliii

• Uninsuredwomenuse fewerpreventive servicesandaremore likely todelay carebecauseofcost.xliv

• Additionally, access to improved reproductive health services can help prevent unintendedpregnancies–overhalfofallpregnanciesintheUnitedStatesareunintended.xlv

FIGURE13:DISTRIBUTIONOFPREVENTABILITYAMONGPREGNANCYRELATEDDEATHS

AbilitytoEnhanceOutcomes:

Inordertotrulyprovidemotherswithproactivematernalhealthservices,womenmusthaveaccesstoand a longitudinal relationship with a primary care physician who understands a woman's individual

FIGURE22:DISTRIBUTIONOFPREVENTABILITYAMONGPREGNANCYRELATEDDEATHS


29

health needs at each stage of her life, access to subspecialists who are properly trained to care forwomenhavinghigh-riskpregnanciesorprovidethedistinctperspectiveofpediatricianstreatingyoungwomenorgeriatricianstreatingolderwomen.Assuch,accesstopreventativecareisnotsufficientandthereneedstobeanadequatefocusonimprovingoutcomesachievedinsteadofvolumeofservices.

AbilitytoReduceLong-TermCosts:

• Patient Level: Apart fromdirect cost savings,which is critical to uninsuredmothers, patientsalsoexperienceindirectcostsavingsfromimprovedqualityoflifeandproductivity.

• Provider/SystemLevel:xlvi

• Prenatal care: The cost of caring for babies who weigh less than 1,140 grams (2.5pounds)atbirthisestimatedtobeanaverage$140,000perpatient,bringingtheannualcostofneonatal intensivecare intheUnitedStatestoatotalof$1.5billion.Foreverydollar spentonprenatal care, $3.38 is saved in the costof caring for low-birth-weightinfants.

• ReproductiveHealth:Totalpublicexpenditureonunintendedpregnanciesisestimatedtobe$21billionperannum.

Conclusion

TheWomen’s Health Bond will prioritize initiatives that can increase effectiveness and efficiency byfocusingonsupportingpreventionandearlydetectionorreducingdelaystotreatment(Figure14).The‘Bond Blueprint’ section of this report also provides an overview of a potential bond structure (theHumanityBond)thatwouldbewellsuitedtofundinterventionssupportingproactivehealthcare.The‘BondBlueprint’sectionwillalsoprovideexamplesofinitiativesthatcouldbenefitfromupfrontfundingunlocked through a Bond thatwould allow them to bothmagnify impact on end beneficiarieswhilereducinglong-termcosts.

FIGURE14:WHBAPPROACHTOEMBRACEPROACTIVECAREACROSSTHECONTINUUM

PatientLevel

ProviderLevel

SystemLevel


Leve

lsofH

ealth

careSystem

ContinuumofCare

•  CervicalCancerVaccination•  AccesstoReproductiveHealthServices

•  ProgramsfacilitatingMammography/Pap-Smears•  Quality-drivenprenatalcareprograms

•  ImprovedPatientNavigationProgramsandContinuityofCare•  Follow-up

postpartumvisits

Type

sofProac

tive

Se

rvices

und

er

Materna

lHea

lth

andWom

en-

Spec

ificCa

ncers

IncreasingTimelinessofTreatment

AcceleratingProactiveHealthcare

ReducingLongTerm

Costs


30

CRITERIA3:TARGETSTATES

The final criterion explores the potential of selected states to align with two factors (i) demand forcapital,i.e.presenceofinnovativehealthcareproviderswithsolutionsthatareequippedtoeffectivelyabsorbanddeploycapital;and(ii)supplyofcapital,i.e.abilitytobringinnewinvestorsfromtheprivatesector into the health care equation based on key investment drivers. Thiswill lay the foundation tocreateaninnovativefinancialmechanismusingpositiveincentivestounlocknewsourcesofcapitalforwomen’s health at the pace and scale required. The following section outlines a series of questionsassessed as part of the feasibility study to support the decision-making process to narrow down thethreetargetstatesofCalifornia,MinnesotaandNewYork.

Question 1:Are there fundinggaps forwomen’shealth care in theUnitedStates indicating thatcurrentsourcesofcapitaldonotsufficientlyaddresskeyissuesfacedbyunderservedwomenatthepaceandscalerequired?

PUBLICSECTORANALYSIS

HealthcarespendinghasoutpacedthegrowthoftheUSeconomy,outlinedinFigure8.Inadditiontopolicychanges, federal, state,and localbudgetsarebeing furthersqueezedbydemographicchangesandausteritymeasures.Annualhealthcosts for low incomecommunitiesareexpectedtogrowat3%peryear,comparedto0.5%peryearfortherestofthepopulation.xlviiFunding lossesfromchangestotheAffordableCareAct (ACA) could total $172Bbetween 2020-2026xlviii; solutionsmust look beyondonly increasing insurancecoverage to funding initiatives thatwilldeliverpatient-centeredcare that isaffordable,accessibleandcommittedtoimprovequalityofoutcomes.

SPOTLIGHT:INSIGHTSFROMSTAKEHOLDERINTERVIEWS

Accordingtostakeholderinterviews,thetopthreelimitationsofrelyingonpublicsectorfunding(eitherfromthefederalandstatelevel)are:

! Unreliable: Stakeholders interviewed indicated relying solely onpublic sector funding canbeunreliable in the event of policy changes, particularly for organizations focused onmaternalhealth.

! Limited Links to Impact:Stakeholders interviewedindicatedlimitedlinkagesbetweenpublicsectorfundingreceivedandoutcomesachieved,orpatient-centeredapproachadopted.

! Limited Leverage: Stakeholders interviewed indicated there are limited mechanisms usingpublicsectorfundingtoeffectivelycatalyzeadditionalcapitalwhichwillhelptomultiplyimpactachievedatagreaterpaceandscale.

PHILANTHROPICSECTORANALYSIS

Philanthropicfundingforhealthcare,whichwillbeexpectedtomakeupforshortfalls inpublicsectorfunding,accountsforjust$5billionofthetotal$3.3trillionspentannuallyonhealthcareintheUnitedStates (2013).xlixThe total value of grants directed towards women’s and girls’ health issues in theUnitedStateswaslimitedto$520million(2013)butisnotablyonanupwardtrend.l


31

SPOTLIGHT:INSIGHTSFROMSTAKEHOLDERINTERVIEWS

Accordingtostakeholderinterviews,thetopthreelimitationsofrelyingonphilanthropicare:

! Time Consuming: Stakeholders interviewed indicated that to mobilize philanthropic grantstheymust investasignificantamountoftimeandresourcestofund-raiseupfrontandthentoreportonoutputsduringthe lifeofthegrant.Thistakesawayresourcesfromfocusingontheactualwork.

! One-off Grants: Stakeholders interviewed indicated that themajorityof philanthropic actorstend to provide one-off grants with narrowly defined focus areas as opposed to multi-yearsupportwhichwouldallowrecipientstheflexibilitytofocusonsustainingimpactandachievinglong-termoutcomes.

! LimitedLeverage:Stakeholdersinterviewedindicatedthattherearelimitedmechanismsusingphilanthropicsectorfundingtoeffectivelycatalyzeadditionalcapitalwhichwillhelptomultiplyimpactachievedatagreaterpaceandscale.

Question2:Istherepotentialtounlocknewsourcesofcapital,particularlyfromtheprivatesector,to advance health care for underserved women using blended finance or innovative financialmechanisms?

Theconclusionfromtheanalysisofpublicandphilanthropiccapital is that itwillbe imperativetotapinto the~$85 trillion capitalmarkets tomobilizeadditional capital from theprivate sector toaddressfunding gaps that the public and philanthropic sector are not expected to be able to support at therequiredpaceandscale. Theabilityoftheprivatesectortoaddressthesegapsandsupportaproductsuch as a Women’s Health Bond with dual social and financial goals is assessed based on theintersectionoftwomovements:(i)InnovativeFinance;and(ii)GenderLensInvesting.

FIGURE15:EXPLORINGTHEINTERESTININVESTINGINWOMEN’SHEALTH–THEINTERSECTIONOFTHEINNOVATIVEFINANCEANDGENDER-LENSMOVEMENTS

Growinginnovativefinancemovement(risingtrendsintheblendedfinanceandimpactinvestingspacefocusedonhealth)

Growinginterestininvestinginwomen

(risingtrendsingenderlens

investingandbringingwomen

intocapitalmarkets)

InvestinginWomen’sHealth


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GROWINGINNOVATIVEFINANCEMOVEMENT

The innovative finance movement has rapidly evolved over the past decade to bring private sectorcapital into thesustainabledevelopmentequation.Oneof thechannelsof innovative finance, impactinvesting, refers to investmentswith the intention to generate dual social and financial returns. Theestimatedmarketsizeis$228billionli.5%oftotalimpactinvestingmarketsizefocusedonhealthcareinvestmentsindicatingatotalvalueof$11.4billion(Figure16)lii.49%ofimpactinvestorshavehealthasoneoftheirfocussectorsliii.

FIGURE16:TAPPINGINTOTHEIMPACTINVESTINGMOVEMENTTOFINANCEHEALTHCARE

GROWINGINTERESTININVESTINGINUNDERSERVEDWOMEN

Thereisagrowinginterestacrosstheworldfromtheprivatesectortoinvestinwomenempowermentandfromthephilanthropicsectortofundinitiativesfocusedongenderequality.Thisservesasthebasisforanopportunitytostructurean innovativefinancialmechanismthat leveragesexistingcapital fromphilanthropicactorstounlockupfrontfundingfromtheprivatesector.

Additionally, there is an increasing focus around gender equality and empowerment in the UnitedStates, further indicating there will be market interest in participating in innovative financialmechanismsfocusedon improvingthe livesofunderservedwomen.This issupportedbythegrowingrecognition thatempoweringwomenwithaffordable,qualityhealthcareshouldbeviewedasabasichumanright,notaprivilegecontingentonthewomen’ssocio-economicstatus.OnereasonforgrowinginterestininvestinginwomeninAmericaiswomen’srateofparticipationinthelabormarketrosefrom34% in 1950 to 57% in2016,puttingmorewealth in thehandsofwomenwho in turn invest inotherwomen.livBetween2010and2015,privatewealthheldbywomengrewfrom$34trillionto$51trillion.lvWomen’s wealth also rose as a share of all private wealth from 28% to 30% and by 2020 they areexpectedtohold$72trillion,32%ofthetotal.lvi

Othermovementssuchas#MeTooand#BlackLivesMatterhave furtherbuiltmomentumfor fundinginitiativesthatempowerwomenandinparticular,thatfocusonaddressingtheneedsofmarginalizedcommunitiesorsegmentsofthepopulationthathavefaceddiscrimination.

Source:GIIN2018


33

Question3:Whichstateshavesupportiveecosystemsforaninnovativefinancialmechanism,bothintermsofpresenceofapipelineofhighimpactinitiativestoabsorbanddeploycapitalandfromaregulatoryperspective?

Table6outlines thekeypositive screening criteria thatplayeda role indetermining the feasibilityoffocusingthefirsttranchesoftheWomen’sHealthBondonCalifornia,MinnesotaandNewYork:

TABLE6

Source:MinnesotaHealthScoreCard,Availableat:https://mnbp.com/wp-content/uploads/2015/02/MBP_HealthScorecard.pdf

POSITIVESCREENINGCRITERIAFORTARGETSTATES

CALIFORNIA

Supportiveenvironmentforgenderlensinvestingandwomen’sreproductiverights:

-Californiahasastronghistoryofsupportingwomen’srightsandbuildinganinclusivecommunitythatembracesundocumentedwomen.

-Assuch,whenassessingthefeasibilityoftheWomen’sHealthBondfromthedemandsideoftheequation,Californiahasarelativelystrongerpipelineofhigh-impactinitiativesthatcanpotentiallyabsorbanddeploycapitaltoprovideunderservedwomenwithaccesstoaffordable,qualityhealthcare.-Whenassessingthesupplysideoftheequation,therearealargenumberoflocalfoundationsinterestedinsupportingwomen’shealth(refertotheecosystemmappingsectioninthisdocumentforalistofecosystemactorsidentifiedthatarebasedinCA).Thesefoundationscanserveaspotentialpartnersinblendedfinancialvehiclesthatusegrantcapitaltoleverageprivatesectorinvestments.

NEWYORK

Previoustrackrecordsupportinginnovativefinancialmechanismsandrelativelygreaterunderstandingofimpactinvestingamongphilanthropicfunders:

-NewYorkwashometothefirstSocialImpactBondintheUnitedStates,focusedonreducingrecidivisminRiker’sIsland.AlthoughtheBonditselfwasnotsuccessful,itlaidthefoundationforinvestorinterestinalternativevehiclesforfundingpressingsocialissues.-Additionally,NewYorkservesastheheadquartersforanumberoffoundationsthathavesupportedtheimpactinvestingspaceinthepast,includingtheRockefellerFoundationwhichcoinedtheterm‘impactinvesting’in2008.-Assuch,thereisarelativelystrongerunderstandingofinnovativefinanceascomparedtootherstates,increasingthelikelihoodofsuccessforinitialtranchesoftheBondiftheyarefocusedonNewYork.

MINNESOTA

Stronglinksbetweenhealthcaresectorandgrowthofthestateeconomyandhighlevelofprivatesectorinvolvementinthesectorincreasesthelikelihoodoflocalinvestorparticipationandcorporatesupport:

-Thehealthcaresector,vitaltothestate’seconomy,accountsforalargeandgrowingportionoftheemploymentbase;16ofthestate’stop50employersarehealthcarecompanies,whichrepresent32%ofMinnesota’sjobs.-Healthcareprovidersaloneemployedmorethan16%oftheworkforcein2010andareoneoftheeconomy’sfastest-growingsegments.-Throughitsactiveinvolvementandleadershiponhealthcareissues,theprivatesectorhascreatedastrongfoundationforcollaborationwiththestateandauniqueplatformfromwhichtoeffectchange.Thisincreasesthelikelihoodoflocalinvestorsandlocalcorporatesbasedinthestatetoparticipateinthebondissuance.


34

Question4:Instateswhereaninnovativefinancialmechanismisexpectedtobefeasible,isthereaclear need to mobilize capital, both in terms of absolute need and acuity of need (focusing onwomen-specificcancers,maternalhealthandreproductiverights)?

The final question will reassess the ability of the Bond to achieve desired outcomes in target statesdeterminedasfeasiblebyreviewingkeystatisticsrelatedtobothabsoluteneedandacuityofneed interms of the specific health issues narrowed down as part of the first criteria –maternal health andwomen-specificcancers.

Table 7 summarizes the key statistics related to absolute need of underserved women in the threetargetstates.

TABLE7:ABSOLUTENEED–SUMMARYOFKEYSTATISTICS

KeyIndicator California Minnesota NewYork

#ofwomen(age18andolder) 15,283,600 2,132,700 8,042,900

%womenbelowpovertyline 14% 10% 13%

#womenbelowpovertyline 2,139,704 213,270 1,045,577

%womenreportingpoorhealth 20% 20% 21%

#womenreportingpoorhealth 3,056,720 426,540 1,689,009

#ofcriticalaccesshospitals 34 78 18

#ofruralhealthclinics 280 89 9

#offederallyqualifiedhealthclinics 194 16 65

#ofwomenwithouthealthinsurance 1,776,848 249,391 710,436

% of women not seeing doctor due to

cost

(inthelast12months)

20%

White:17%

Black:23%

Hispanic:26%

18%

White:15%

Black:-

Hispanic:26%

17%

White:15%

Black:23%

Hispanic:33%

Sources:USCensusReports2017,KaiserFamilyFoundationStateProfilesforWomen’sHealth,Statistica

Table 8 summarizes the key statistics related to acuity needof in the three target states in termsofwomen-specificcancersandmaternalhealth.


35

TABLE8:ACUITYOFNEED–SUMMARYOFKEYSTATISTICS

KeyIndicators California Minnesota NewYork

BreastCancerIncidence(per100,000women) 118.7 130.9 132.3

BreastCancerDeaths(per100,000women) 20 17 19.2

CervicalCancerIncidence(per100,000women) 6.9 4.8 7.3

CervicalCancerDeaths(per100,000women) 2.3 1.3 2.4

CervicalCancerScreening(%ofwomenaged18–44) 79.6% 81.1% 78.4%

LowBirthWeight

7%White:6%Black:12%Hispanic:

7%

6%White:6%Black:9%Hispanic:6%

8%White:6%Black:12%Hispanic:8%

MaternalMortality(deathsper100,000births) 4.5 13 20.6

PostpartumDepression (%ofwomenwitha recentlivebirth)

13% 9% 12.2%

DedicatedHealthCareProvider(%ofwomenaged18–44)

71.7% 72.4% 80%

Alcohol During Pregnancy (% of pregnant womenaged18–44)

7.6% 5.4% 8.3%

NoPostpartumVisit (%ofwomenwitharecentlivebirth)

12.5% 9.1% 8.9%

Sources:USCensusReports2017,KaiserFamilyFoundationStateProfilesforWomen’sHealth,Statistica

OTHERKEYFACTORSTOASSESSABSOLUTEANDACUITYOFNEEDINTARGETSTATES

Besides focusing on absolute number of low-incomewomen or rural communities, other key factorsmapped as part of the analysis including number of undocumented women, uninsured women andwomenofcolor.

Undocumentedwomen:Figure17mapstheundocumentedpopulationintheUnitedStates.

Keyinsight:Californiahasbyfarthelargestnumberofundocumentedimmigrants(about2.3millionin2014).About six-in-ten undocumented immigrants live in California, andNewYork (twoof theWHBtargetstates)andinFlorida,Illinois,NewJerseyandTexas.lvii


36

FIGURE17:ESTIMATEDUNDOCUMENTEDPOPULATION(2014)

Uninsuredwomen:Figure18mapstheuninsuredpopulationintheUnitedStates.

Keyinsight:CaliforniaandNewYorkarebothrankedinthetoptenprioritystatesintermsofabsolutenumberofuninsuredorunderinsuredwomen.lviii

FIGURE18:ESTIMATEDNUMBEROFWOMENWHOAREUNINSURED(2014)

Ethnic/racialdiversity:Majorityofunderservedwomenareexpectedtobenon-whites.BothNewYorkandCaliforniafeatureamongthegivemostdiversecountiesintheU.S.,whichinclude:lix

• Queens County, New York (27.6% white/non-Latino, 17.7% African American, 0.3% NativeAmerican,22.8%AsianAmerican,27.5%Latino,and4%other)

• Alameda County, California (34.1% white/non-Latino, 12.2% African American, 0.3% NativeAmerican,25.9%AsianAmerican,22.5%Latino,and5.1%other)

• Solano County, California (40.8% white/non-Latino, 14.2% African American, 0.5% NativeAmerican,14.3%AsianAmerican,24%Latino,and6.2%other)


37

SpotlightonAbsoluteNeedofReproductiveRights:Figure19mapstheunintendedpregnancyrateintheUnitedStates.lxCaliforniaandNewYork ranked in the toptenprioritystates in termsofabsolutenumberofwomeninneedofreproductiveservices.lxi

FIGURE19:MAPPINGUNINTENDEDPREGNANCYRATEPER1000WOMEN,15-44

Spotlight on Minnesota: Minnesota consistently performs well across various national healthperformancescorecards.However,notallwomenresidinginthestateareequallylikelytobereflectedintheserankingsbecausethestatehassomeofthe largestracial,ethnicandgeographic inequities inhealth status and incidence of chronic disease in the country particularly among undocumentedcommunities.Keystatisticsincludelxii:

• Minnesota’s foreign-born population is increasing faster than the national average, tripling since1990whilethenationalaveragehasonlydoubled.Onlyaboutone-thirdofMinnesota’simmigrantswereborninLatinAmerica,comparedtomorethanhalfofimmigrantsnationally.Similarly,oneinfiveMinnesotaimmigrantswereborninAfrica,comparedtoonly4%nationally.TheTwinCities,inparticular,ishometoarelativelylargeAmericanIndianpopulation,includingmembersoftheLittleEarthofUnitedTribesandShakopeeMdewakantonSiouxcommunities.lxiii

• Asian immigrants tended tohavehigheroutcome ratesacrossmultiplemeasuresandgeographicareas. In fact,Vietnamese immigrantshadthehigheststatewiderateforoptimaldiabetescareofany racialorethnicgroup. In theWestMetroRegion,64percentofVietnamese immigrantswerereceivingsuchcare.TherewasoneexceptiontothesehigherratesamongAsianimmigrants:thoseborn inLaos.Theygenerallyhad lowerhealth careoutcomes thanotherAsian-bornpatientsandotherpatientsingeneral.lxiv

• Womenof color inMinnesotaare less likely to receivepreventivecare,more likely to suffer fromserious illnesses and have less desirable health outcomes, and less likely to receive clinically-necessary procedures and services. Racial and ethnic disparities accounted for an estimated $60billioninexcesshealthcarecostsin2009.lxv

As such,Minnesota is currently being considered as a potential focus state for theWomen’s HealthBond,eventhoughitdoesnothavethesamescaleofissuesasothertargetstates.


39

BLUEPRINTOFTHEWOMEN’SHEALTHBOND

Thepurposeofthissectionistooutlinethedecision-makingprocessbehindthedesignoftheWomen’sHealthBondandreviewpotentialinnovativestructuresthatmaybesuitable.Toaddressthisquestion,IIXadoptedathree-stageanalysisasoutlinedinFigure20anddescribedindetailbelow:

FIGURE20:DESIGNINGTHEBLUEPRINTOFTHEBOND

Whatistheexpectedprofileofrelevanthealthcareentities?

Relevanthealthcareentitiesforthisanalysisneedtomeetthreemaincriteria:

(i) Clearfocusontargetingunderservedwomen

(ii) Existinginitiativesthataddressthechallengesfacedbythesewomen

(iii) Clearneedforadditional/alternativesourcesofcapital

Based on the aforementioned criteria, relevant health care entities are typically non-profit initiativeswhichindicatestheneedtomobilizeacombinationofdebtandgrantcapital(non-profitentitiescannotabsorbequitycapitalorvariantsofthesame).Theexpectedprofileandneedsofthesenon-profitsvary:

- 501c3entities (eg:BlackWomenforWellness),professionalassociations (eg:AmericanCollegeofObstetrics and Gynecologists) and national level voluntary health organizations (eg: AmericanCancer Society) that run innovative patient-centered programs and need more flexible fundingoptionstoenhancethepaceandscaleoftheirimpactonunderservedwomen.

- Hospitals thathavean innovativenew initiative that isunequipped to tap into traditional fundingsourcesfromeitherthecapitalmarketsorfromfederalorstatelevelgrants(eg:BuildingaMother’sCenterbyNewYorkPresbyterian).

- FederallyQualifiedHealthClinicsandCommunityHealthClinicsthatdonotbenefitfromthecapitalmarketsatthesamelevelaslargehospitals.However,theseentitiescanonlyabsorbasmallportionofcapitalperyearwhichmaymandatethattheybeaggregatedintoaportfolio.

Whatarethefundingbarriersthattheseentitiesfaceandwhichofthese

canbeaddressedbyinnovativefinancialmechanismsuchasa

Women’sHealthBond

Whatbondstructureswouldbemostsuitabletounlocktherighttypeofblendedcapitaltoenabletheseentitiestocreatedemonstrable

outcomesonunderservedwomen

FundingBarriersFacedbyEntities

TypeofFundingaBondcanUnlock

Targetunderserved

women

Haveinitiativesthat

addresschallengesidentified

Needadditional/alternativesourcesofcapital

PotentialBond

Mechanism

Whatistheprofileofhealthcareentitiesbasedon(i)abilitytotargetunderservedwomen;(ii)existing

initiativesaddressingchallenges;(iii)needforadditionalcapital


40

Whatarethekeyfundingbarriersfacedbytheseentities?

Based on stakeholder interviewswith potential recipients of funding, IIX has identified the followingfundingbarriersthattheWomen’sHealthBondwouldneedtoaddress:

(i) Time Consuming: Long process to solicit grants from philanthropic funders and resource-intensivereporting

(ii) One-offGrants:Grantsareoftennotmulti-yearresultinginlimitedfocusonlong-termprogramperformance

(iii) LimitedLinkstoImpact:Fewcontractslinkcapitalmobilizedwithforward-looking,outcomes-focusedM&E

(iv) Limited Leverage: Limited ability for current funding to catalyze new sources of capital, nomultipliereffect

(v) Unreliable:Fundingfrompoliticalsourcesinparticulartendtobeunreliableandcontingentonpolicychanges

Whatinnovativebondstructureswouldbemostsuitable?

IIXisexploringavarietyofinnovativefinancialmechanismswhiledesigningtheWomen’sHealthBondas outlinedbelow.The following sectionwill provide anoverviewof howeach structureworks and acomparativeanalysistodefinethemechanismthatwouldbemostsuitedtofundhealthcareentitiesinthe United States. The unique merits and drawbacks of each of the different structures have beendiscussedwithTaskForcemembers,healthcareexpertsandpotentialentitiesthatwillbe included intheBondtosolicitdiversefeedbackanddrawarangeofperspectives.

PotentialStructure1:SustainabilityBond

Aninnovativedebtsecuritythatmobilizesinvestmentcapitalfromtheprivatesectorandisrepaidbyapoolofborrowersachievingdualsocialandfinancialreturns

FIGURE21:OUTLINEOFSUSTAINABILITYBONDMECHANISM

SUSTAINABILITYBOND

PRIVATESECTORINVESTORS

BANKINGPARTNERS LEGALPARTNERSPORTFOLIOMANAGER

ANDLEADSTRUCTURER

GUARANTEEPARTNER(FOUNDATION/GOVERNMENT)

FINANCIALLYSUSTAINABLEIMPACT

ENTERPRISE


ENTERPRISE


ENTERPRISE

FIGURE33:OUTLINEOFSUSTAINABILITYBONDMECHANISM


41

OutlineofSustainabilityBondFundingFlows

1. Theleadstructurerconductsanupfrontsocialduediligencetocreateaportfolioofhigh-impact,financiallysustainable initiativesthatcanabsorb,deployandrepaydebt;theportfolioaimstohaveanattractiverisk-return-impactprofile

2. Private sector investors provide upfront funding with the intent to generate both social andfinancial returns; the investors typically benefit froma de-risking facility either providedby afoundationorgovernment

3. ProceedsoftheBondarelenttounderlyingborrowersinYear1whogeneratesteadyrevenuestreamsthroughtheiroperations,allowingthemtopayannualcouponpaymentsandtoreturntheprincipleattheendofthebondtenor

4. Investors receive regular coupon payments and impact reporting conducted by the portfoliomanageracrossthebondtenorandthereturnoftheirprincipalatmaturity;thebondsarealsolisted on stock exchanges giving investors the option to trade the security, thereby creatingliquidity

PotentialStructure2:SocialImpactBond

A pay-for-performancemechanism thatmobilizes philanthropic capital and is typically repaid by thepublicsectorindevelopedcountriesorbyadonoragencyorfoundationindevelopingcountriesifpre-determinedoutcomesareachieved.

FIGURE22:OUTLINEOFSOCIALIMPACTBONDS

SOCIALIMPACTBONDS

UPFRONTINVESTORS/FUNDERS

PORTFOLIOMANAGERANDLEAD

STRUCTURER

THIRD-PARTYOUTCOMEPAYER(GOVERNMENT/FOUNDATION)

NON-PROFITTHIRDPARTYIMPACT

VERIFIER

FIGURE35:OUTLINEOFSOCIAL/DEVELOPMENTIMPACTBONDS


42

OutlineofSocialImpactBondFundingFlows

1. Theleadstructureridentifiesanon-profitthatisaddressingaparticularsocialprobleminacost-effectivemannerandassesseswhetherathird-partyoutcomepayer (government/foundation)will experienceclear cost savingsand therebybewilling to repay investors if the interventionsuccessfullyachievespre-determinedoutputs/outcomes

2. Investors/funders (typically philanthropic in nature although theoretically, this could includetraditionalprivatesectorinvestors)provideupfrontfundingto‘buy’thebonds

3. Proceedsofthebondareusedtoscalenon-profitinterventions

4. Athird-partyimpactverifierassesseswhetherpredeterminedoutputs/outcomesaremet

5. If the resultsarepositive the third-partyoutcomepayer repays theupfront investors/-funderstheirprincipalplusacoupon(theamountofthecouponmayvarybasedonthelevelofimpactachieved).

PotentialStructure3:HumanityBond

Ahybridoftheprevioustwostructures,theHumanityBondcombinestheabilitytouseblendedfinanceto bring in upfront funding from private sector actors similar to the Sustainability Bond whilemaintaining a commitment to achieving patient-centered outcomes and linking impact to capitalmobilizedsimilartoSocialImpactBonds.Thestructureisbestsuitedforproactivehealthcareinitiatives(particularlypreventionorservices the reducethedelayto treatment) that requireupfront fundingtoaddresshealthissuesatagreaterpaceandscale–thisallowshealthcareproviderstomagnifyimpactorsavemore lives todaywhile effectively lowering future costsoutlays.Themechanicsof theBondaredescribedbelow:

FIGURE23:OUTLINEOFTHEHUMANITYBOND

HUMANITY BOND PRIVATE SECTOR INVESTORS

BANKING PARTNERS LEGAL PARTNERS LEAD STRUCTURER

ULTIMATE PAYER (FOUNDATION)

NON-PROFIT OR IMPACT

ENTERPRISE


ENTERPRISE


ENTERPRISE

FIGURE37:HUMANITYBONDMECHANISM


43

OutlineofHumanityBondFundingFlows1. The lead bond structurer (or portfolio manager) conducts an upfront social due diligence to

createaportfolioofpatient-centered,time-sensitiveinitiativesthatwouldbenefitfromupfrontfundingbyincreasingtheirimpacttodayandreducingcostoutlaysinthefuture.

2. Privatesectorimpactinvestorsprovideupfrontfundingwiththeintenttogeneratebothsocialandfinancialreturns.

3. ProceedsoftheBondareusedtoscaleupandacceleratetime-sensitive initiativesbythepre-selectednon-profitsorimpactenterprises.

4. Athird-party‘ultimatepayer’repaysthebondthroughpre-committedfundingstreams.Thisistypically an organization with vested interest in improving health outcomes for women (forinstance,afoundation,corporateCSRarmorgovernmentbody).

5. Investorsreceiveregularimpactreportingconductedbytheportfoliomanageracrossthebondtenorandthereturnoftheirprincipalatmaturity.

TheHumanityBond followsa similar structureas ‘GAVI’bonds. Issuedbytheinternationalfinancefacilityfor immunization(IFFIm),GAVIbondshaveraised+US$6.5billiontodatefromcapitalmarketinvestors upfront; the repayment is secured against committed pledges for future donations fromgovernmentssuchastheUK,Japan,andFrance.lxviWiththeproceeds,theGlobalAllianceforVaccinesandImmunizations(GAVI)hasbeenabletoconductlarge-scalevaccinationprograms,savingmorelivesthan could be achieved by spreading these programs over time. In this case, the governments arerepaying the bond which means these bonds are considered low-risk, low-return investment gradebonds.FitchRatings,Moody's InvestorServiceandStandard&Poor'shaveratedIFFImasAA/Aa1/AAandcouponsvarybasedoncurrency(average~2%).lxvii

FIGURE24:OUTLINEOFGAVIBONDMECHANISM

KeyInsight:CustomizationfortheWHB

IfthehumanitybondstructureistobeadaptedfortheWHB,itispossibletohaveafoundationortheCSRarmofacorporaterepaytheinvestorsinsteadofagovernment.Thebenefitofusingthisstructureinsteadofatraditionalgrantistheabilityforthefoundationtounlocklarge-scalecapitalinYear1andthenrepaythebondovertime.Thiswillhelpacceleratetheachievementofoutcomesandisbestsuitedto initiatives focused on prevention and early detection that typically are more cost effective thantreatment. It isalsoaneffectiveway tobringnewactors fromtheprivate sector into theU.S.healthcare equationwhichwill have a ripple effect of galvanizing anew set of stakeholders invested in thestrengtheningthehealthcaresystemandcommittedtoempoweringunderservedwomen.

ComparativeAnalysis

Basedonthefollowingcomparativeanalysisofthethreepotentialbondstructures,theHumanityBondisthemostsuitablefortheWomen’sHealthBondduetotheclearalignmentwithIIX’sthreeprinciples–patient-centered,proactiveandpositiveincentives.

IssuerofGAVIBonds

CapitalMarketInvestors

VaccinationPrograms

Beneficiaries Beneficiaries Beneficiaries

GAVIBonds

$$$

$$$$$$$$$

GovernmentDonors

FIGURE38:OUTLINEOFGAVIBONDMECHANISM


44

TABLE9

HUMANITYBOND:PUTTINGWOMENFRONTANDCENTEROFCAPITALMARKETS

It is imperative to put women front and center of capital markets by developing more innovativefinancialinstrumentsthatgobeyondphilanthropyandtrulymakethecaseforinvestinginwomenforamore resilient, equitable future. It is also important to create a financial instrument that balances astrong commitment to outcomes with the ability to bring new private sector investors into thehealthcareequationintheUnitedStatestocomplement(notreplace)currentphilanthropicefforts.TheHumanityBondisdesignedtoachievethisinthreeways:• Bringing in new private sector capital to invest inwomen and creating liquidity:Social Impact

Bondsshifttheentirefinancialrisktoinvestors;ifoutcomesarenotmetbytheentityreceivingthecapital investors are not repaid – as such, this tends to attract philanthropic investors such asfoundations.TheHumanityBondisdesignedtogobeyondphilanthropicfundersbecausetheentirefinancialriskisnotshiftedtotheinvestors–investorsarepaidtheirprincipalbackregardlesstherebyunlockingnewsourcesofcapitalatamuchlargerscalefromtraditionalprivatesector investors(asseeninthecaseoftheGAVIBondsonPage43).Additionally,theHumanityBondcanbelistedonastock exchange, which will create liquidity for investors as well as transparency of results for allstakeholders involved. This is an important step towards having more gender-lens investmentproductsonthemarketthattrulybuildthecaseforinvestinginwomenintheUnitedStates.

• Incentivizing social outcomes and ensuring commitment to transparent, accountable results:The Humanity Bond rewards both investors and the entities (who are actually responsible for

COMPARATIVEANALYSISOFPOTENTIALBONDSTRUCTURES

SUSTAINABILITYBOND

KeyFeatures

-Effectivelyengagesmultiplestakeholders

-Aggregatesapoolofentitiestocreateanattractiveportfolio

-Idealforprivateinvestment

-Suitableformission-drivenfor-profitandfinanciallysustainablenon-profitentities

-Outcomesmeasuredpre-emptivelyandreportedacrossbondtenor

-Canbelistedonastockexchangetoallowforliquidity

Drawbacks

-Requiresfinanciallysustainableentitieswithclearborrowingneedsandrepaymentability

-CapitalmarketsintheUnitedStateshighlyefficientsowillnotbenefitlargefinanciallysustainablenon-profitsorsmallfor-profits

SOCIALIMPACTBOND

KeyFeatures

-Bringsinmultiplestakeholdersfrompublicandphilanthropicsector

-Linksoutcomesachievedtorepaymenttoinvestors

-Idealforunlockingphilanthropiccapital

-Suitablefornon-profitentitieswiththird-partyoutcomepayer

Drawbacks

-Shiftsentirefinancialrisktoinvestors;thiscreatesatendencytobringincapitalthatwouldhavebeenusedforphilanthropicpurposesanywayresultinginlimitedadditionalityandliquidity

-Relativelyexpensivetomeasureandverifyimpact;takesaretrospectiveapproachtomeasuingresults

HUMANITYBOND

KeyFeatures

-AlignmentwithPrinciple1"PatientCentered":Ensuresupfrontsocialduediligenceonunderlyingentitiestoassessandprojectpatient-centeredoutcomesandongoingreportingofimpactachievedtotherebyensuringtransparencyandaccountabilitytobothpatientsandinvestors

-AlignmentwithPrinciple2"Proactive":Idealforscalingpreventiveorearlydetectioninitiativesthatsavemorelivestodayandreducelargeroutlaysofcosttomorrow

-AlignmentwithPrinciple3"PositiveIncentives":Leveragesphilanthropiccapitaltounlocklarge-scaleinvestmentfromprivatesectoractorsthatwouldnothaveparticipatedotherwise,therebyachievingamultipliereffect.Doesnotshifttheentirefinancialriskofachievingsocialoutcomestoprivatesectorinvestors(i.e.doesnotusenegativeincentives


45

creating outcomes)with a potential ‘upside’ or share in the coupon payment if the outcomes aremet.This isauniquewaytousepositive incentives toencourageacommitment tocreatingsocialoutcomesamongallpartiesinvolved(insteadofonlypenalizinginvestorsifoutcomesarenotmet).Additionally,theentitieswillgothroughasocialduediligenceusingtheImpactAssessmentToolkitdescribedinthenextsectionbeforereceivingtheinvestment–thiswillensureimpactcreatedwillbeassessedupfront,projectedinaforwardlookingwaywithcleartargetsandthenreportedonacrossthelifeofthebond(notjustattheendofthebondtenor)tocreatetransparency.

• Enhancingefficiency and supportingproactivehealthcare interventions:Finally,theprojectwillensurethatinitiativesthatbenefitmorefromfundingtodayratherthanfundingspreadovertimeareprioritized.Thiswillbeassessedbothfromacostperspective(consideringhowmuchwillbesavedbyspendingonprevention/earlydetectioninsteadofexclusivelyontreatment)andfromanimpactperspective(abilitytosavemorelivesandreducemorbidityormortalityifweinvesttodayinsteadofprovidinggrantsoveranumberofyears).Acceleratingaccess toupfront fundingwillalsohelp theentities receiving the capital to create internal efficiencies instead of constantly fundraising ordesigning new programs every year, which is a time, capital and resource intensive process thatdetractsorganizationsfromfocusingoncreatingpatient-centeredoutcomes.

NEXTSTEPS:WOMEN’SHEALTHBONDSERIES

Basedonfindingsfromthefeasibilitystudy,IIXwillissueaseriesofWomen’sHealthBondswithagoaltomobilize$100millionoverthenext~5years.Thiswillalloweachbondtofocusonasinglestatewhichwillreduceadministrativecostsandcomplexityofdealingwithnuancedregulatoryrequirementslinkedto financial securities that vary based on states. Smaller bond sizes also are alignedwith findings onfunding needs of individual entities that range from$1million to $20million. Each of the bondswillfocusononeofIIX’stargetconditions:women-specificcancers,maternalhealthorreproductiverights.Over time, bonds issued will evolve based on learnings from previous issuances to either scale upexistinginitiativesinnewcounties,bringsuccessfulinterventionstonewormorecomplexstates,widenthebreadthofissuesacrossthehealthcarecontinuumorintroduceothercomplexitiesinthestructureto magnify the impact on women or to makemore efficient use of the capital mobilized. The nextsectionincludesexamplesofpotentialinitiativesthatcouldbenefitfromaninnovativebond.

FIGURE25:5-YEARROADMAPFORWOMEN’SHEALTHBONDSERIES

ILLUSTRATIVECASESThe following section outlines two illustrative case of how the Humanity Bond mechanism can becustomizedfortheWomen’sHealthBond:

• Case1:AmericanCancerSocietyHPVVACandSustainabilityInitiative• Case2:TheMother’sCenteratColumbiaUniversityIrvingMedicalCenter

SummaryofPotentialThematicFocusAreas:

FIGURE39:FIVEYEARROADMAPFORWOMEN’SHEALTHBONDSERIES

PrenatalCare PostpartumCare ReproductiveJustice BreastCancer CervicalCancer

2018 2019 2020 2021 2022

•  ConductFeasibilityStudy•  CreateIAToolkit•  GalvanizeEcosystemto

SupportPhase2•  StructurethefirstWHBin

theseriesandplacewithinvestors

Continuedimpactassessment,monitoringandreportingtoinvestorsandotherstakeholdersusingIAToolkit

•  RevisefeasibilitystudyforWHB2

•  StructureWHB2andplacewithinvestors








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Case1:AmericanCancerSocietyHPVVACandSustainabilityInitiativeACS InitiativeGoals:ACSproposestolaunchitsHPVVACprogramwiththedualgoalsto(i)eradicatecervical cancer inMNover the courseof 10yearsbasedon the successof itspilotproject; and (ii) tocreatesustainabilityinACS’sownoperations,enablingittoscaleupandreplicatetheprograminotherstatesgoingforward.PilotProjectOverview: TheACSHPVVACsPilotProjectaimed to increaseHPVvaccination rates foradolescents nationwide, with a focus on adolescents ages 11 to 12, through improved providerawareness and education and improved system-wide processes. The project expanded theAmericanCancerSociety’sexistingcancerpreventionandearlydetection interventionswithFederallyQualifiedHealthCareCenters (FQHCs)andCommunityHealthCenters (CHCs).Theprojectmodel centeredonAmericanCancerSociety(ACS)primarycarestafftoworkwithpartnerFQHCstowardincreasingHPVvaccination rates. All partner FQHCs were given an upfront grant along with technical assistance tosupport staff training, modify their electronic health records and implement four core interventionstrategies to increase HPV vaccination rates in their target communities: (i) client reminders; (ii)providerprompts;(iii)standingorders;and(iv)providerassessmentandfeedback.AlignmentwithIIXPrinciplestoAdvanceWomen’sHealthPatientCenteredCare–TheexpectedhealthoutcomesoftheACSinitiativeinclude:

TheNeedforUpfrontFundingtoAdoptaProactiveApproach:• Theprimarypurposeof the fundingwillbetosupportpreventionofcervicalcancerby improving

HPVvaccination initiationandcompletionratesandearly detectionbysupportingpapsmearsorreducing time to treatment. Part of the proceeds will be used to build awareness among rural,undocumentedandwomenofcolorthattendtobemorereactivewiththeirhealthcare.UpfrontfundingwillhelptoacceleratewidespreadadoptionoftheHPVvaccine inMNwiththebenefitofsavingmorelivestodayandreducinghigherfuturecostsassociatedwithtreatment.

• Additionally,thefundingwillhelpallowIIXtoprovideACSwithadvisorysupporttobuildtheirowninternal sustainability to roll out similar proactive health programs in a more cost-effective,sustainablemannergoing forward.Thisbenefitwill be to reduce thepressureof fundraisingandprogram management costs in the future, allowing ACS to deliver services in a more scalablemanner.

BondMechanismOutline:ThefollowingillustrativeexampleoutlineshowtheWomen’sHealthBondcanusetheHumanityBondstructuretosupporttheACSinitiative,usingpositiveincentivestomobilize$10millionofupfrontcapitalfromprivatesectorinvestors.

Responsiveness:Improvingtimelinessofcarebyincreasingcapacityof

FQHCtoeffectivelyscreenforcervicalcancer

Access:ImprovingproximityofHPVvaccinationservicesforruralwomen;

providingvaccinationservicesforadolescents(bothyounggirlsandyoungboys)

Efficiency:ImprovingACS’sownsustainabilityoverthelongrun;improvingFQHC

efficiencybyupdatingelectronichealthrecords,etc.Equity:Increasingawarenessofcervicalcancerrisksamongat-risksgroups,

prioritizingundocumentedwomen,womenofcolorandethnicminoritiesQuality:ReducingcervicalcancermortalityratesinMNbyincreasingHPV

vaccinationrates(bothinitiationandcompletion)Affordability:ProvidinggrantsupporttoFQHCtoensuretheservices/training

arenotcostprohibitiveorexclusivetohigherincomegroups

ACCESS



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FIGURE26:ILLUSTRATIVEEXAMPLEOFWOMEN’SHEALTHBONDFORAMERICANCANCERSOCIETYHPVVACANDSUSTAINABILITYINITIATIVE

1. IIX designs mechanics of Women’s Health Bond for ACS and conducts upfront social due

diligencetoassesspatient-centeredoutcomesonunderservedwomenandestimateprojectedimpactthatcanbeachievedacrossthebondtenor;

2. Privatesectorimpactinvestorsprovideupfrontfundingof~$10millionbybuyingtheWomen’sHealthBond;

3. Proceedsof thebondaredistributedtoAmericanCancerSocietyto (i) rolloutcervicalcancerprograminMN;and(ii)tobuildinternalsustainabilityofACSoverthelifeoftheBond;

4. IIXverifiesandreportsimpactachievedonunderservedwomenacrossthelifeoftheBond;5. Athird-partyultimatepayer–potentiallytheCSRarmofacorporatewithoperationsinMN–

repaysthebondthroughpre-committedfundingstreamsattheendofthebondtenor;6. Investorsreceivethe$10millionprincipalatmaturity.Anycoupontobepaidtoinvestorswillbe

determined when developing the bond based on efficiencies created (improved patient-centeredoutcomes for the samecostor increasedcost-efficiencies)and timevalueofmoney(based on cost of proactive prevention and early detection are lower than cost of reactivetreatment).

AMERICANCANCERSOCIETY

Objective1:Reducingcervicalcancermortalityamong

underservedwomeninMN

Objective2:ImprovingACS’sownsustainabilityinthe

long-run

IMPACTINVESTMENT

EXCHANGE(IIX)

ULTIMATEPAYER


1

2

3

5

6

4

HUMANITYBOND

Ongoingimpactassessmentandreporting

Bonddesignandadvisory

Upfront$10millioninvestmentmobilizedinYear1

Repaymentofcapitalattheendofbondtenor(eg:Year5)

Fundusedtoscaleupproactive,time-sensitiveinitiatives


48

Case2:TheMothersCenteratColumbiaUniversityIrvingMedicalCenter

Themajorityofwomen(estimatedat85%inNewYorkState)thatexperienceamaternaldeathhaveanidentifiable risk factor with an average number of 2.5 risk factors permaternal death. Non-Hispanicblackwomenare3-4xmorelikelytoexperienceamaternaldeaththanwhitewomennationally,and12xmorelikelyinNewYorkCity.

TheMothersCenteratColumbiaUniversityIrvingMedicalCenterisafirst-of-its-kindspacededicatedtomoms at increased risk for maternal morbidity and mortality. Over 25% of the patients seen byphysicians since2013havehadcardiacdiseaseduringpregnancy;over 18%haveaplacentaldisorderputtingthematsignificantriskofpostpartumhemorrhage;and10%haveaneurologicdisorder.Inthenewcenter, physicians fromacross 16 specialties at themedical centerwill be able to comeTOTHEPATIENTattheMothersCentersothatmomcanmoreeasilyaccessallofthecaresheneedsforasafepregnancyanddeliveryandherphysicianscanmoreeasilycollaborate.

The Center aims to improve maternal health outcomes through multidisciplinary collaboration ofspecialties,healthpromotionefforts,andfollow-upcareincluding:- Optimizedhealthatconceptionforwomenwithexistingmedicalorsurgicalconditions(well-

managedhypertension,diabetes,otherchronicdisease)- Reducedseveremorbidity(bloodtransfusionsandadmissionstoICU)andmortalitythroughrisk

identificationandmitigationaswellasregionalization- Postpartumfollowuptoensurethatwomenwhoexperiencedcomplicationsduringpregnancyhave

accesstothecaretheyneedtomitigatetheirfuturerisk(heartattack,stroke,diabetes).- Increasednutritionandmentalhealthsupportforourmomsfacingahigh-riskpregnancytoreduce

gestationaldiabetes,diabetes,obesity,andantepartum/postpartumdepression.

AlignmentwithIIXWomen’sHealthPrinciples:

PatientCenteredCare–Selectedhealthoutcomesoftheinitiativeinclude:

Responsiveness:Improvingcoordinationofcarethroughmultidisciplinary

careformomswithacuteorchronicmedicalandsurgicalconditions

Access:Improvingproximityandreduceddelaysbyprovidingmotherswith

accesstophysiciansfromacross16specialtiesatthemedicalcenter

Efficiency:Maintainingadatabaseandpopulateresearchconductedbythecenteraroundpregnancy-relatedriskfactors(diabetes,heart-disease,etc.)Equity:TargetbeneficiariesincludealargecommunityfromtheDominicanRepublic,andat-risk,underservedmothersfromacrossNewYorkQuality:Activepreconceptioncounselingandpost-partumfollow-upcare;reducedseveremorbidityandmortalitythroughriskidentification/mitigationAffordability:Supportslow-incomewomen(approximately50%ofpatients

servedhaveinsurancethroughMedicaid)

PatientCenteredOutcomesNYPMaternalHealthInitiative

ACCESS



49

TheNeedforUpfrontFundingtoAdoptaProactiveApproach:

UpfrontfundingwillallowtheMother’sCenterto:- Include supporting services (such as the focus on diabetes and heart disease) to mitigate risks

associatedwithpregnancy;- Reducehigherfuturecostsassociatedwithdelaystotreatmentorlackofadequateearlydetection;- Improve patient quality of life and reduce maternal morbidity and mortality by addressing

preventableissuesattheonset;and- Accelerate funding to the Center to reduce ongoing pressure of fundraising or dependency on

unreliableorinconsistentfunding.

BondMechanismOutline:ThefollowingillustrativeexampleoutlineshowtheWomen’sHealthBondcanusetheHumanityBondstructuretosupporttheinitiative,usingpositiveincentivestomobilizeupto~$5millionofupfrontcapitalfromprivatesectorinvestors.Foundationsplayingtheroleoftheultimatepayer inthepilottrancheoftheprogramcanhelpbuildatrackrecordoftangibleoutcomesandclearcost savings,making a case for public sector actors such as the state government to come in as theultimatepayerinfollowingissuancesoflargersize.

FIGURE27:ILLUSTRATIVEEXAMPLEOFWOMEN’SHEALTHBONDFORTHEMOTHER’SCENTER

1. IIXdesignsmechanicsofWomen’sHealthBondfortheMother’sCenterandconductsupfrontsocialduediligencetoassesspatient-centeredoutcomesonunderservedwomenandestimateprojectedimpactthatcanbeachievedacrossthebondtenor;

2. Privatesector impact investorsprovideupfrontfundingof~$5millionbybuyingtheWomen’sHealthBond;

3. Proceeds of the bond are distributed to theMother’s Center to scale up thematernal healthinitiativefocusedonsupportingunderservedwomeninthecommunity;

4. IIXverifiesandreportsimpactachievedonunderservedwomenacrossthelifeoftheBond;5. Athird-partyultimatepayer–potentiallyafoundationwithvestedinterestinwomen’shealthin

NY–repaysthebondthroughpre-committedfundingstreamsattheendofthebondtenor;6. Investorsreceivethefullprincipalbackatmaturity.Anycoupontobepaidtoinvestorswillbe

determined when developing the bond based on efficiencies created (improved patient-centeredoutcomesforthesamecostorincreasedcost-efficiencies)andtimevalueofmoney.

THEMOTHER’SCENTERATCOLUMBIAUNIVERSITYIRVINGMEDICALCENTER

BONDMANAGER(IIX)

ULTIMATEPAYER


1

2

3

5

6

4

HUMANITYBOND

Ongoingimpactassessmentandreporting

Bonddesignandadvisory

Upfront~$5millioninvestmentmobilizedinYear1

Repaymentofcapitalattheendofbondtenor(eg:Year5)

Fundusedtoscaleupproactive,time-sensitiveinitiatives


51

WOMEN’SHEALTHIMPACTASSESSMENTTOOLKIT

TOOLKITOVERVIEW

Mission andObjectives:TheoverarchingmissionoftheWomenHealthImpactAssessmentToolkitistolinkinvestmentinhealthcareandthecreationofpatient-centeredoutcomeswithafocusonwomen.The toolkitwill alsocomplement IIX'sWomen'sHealthBondby facilitating theupfrontmeasurementandongoingmonitoringofresultsachieved.

Inparticular,theToolkithasthreekeyobjectives:

• To provide patients, particularly underserved women, with a voice in the health care system bydesigningatoolkitthatmeasureswhatmattersmosttothem

• To systematically enable health care providers or programs to transcend the boundaries ofmeasuringoutputs(orvolumeofcare)tomeasuringoutcomes(orvalueofcare)

• Tounlockcapitalfromprivatesectorinvestorsandscalehealthcareprogramsthatembracesixcoredimensionsofhealthoutcomes:access,affordability,efficiency,equity,qualityandresponsiveness.

Toolkit Design and Users: TheWomen’sHealth ImpactAssessmentToolkithasbeenbuiltbasedonIIX’s+9yeartrackrecordofconducting+130impactassessmentsacrosstheworldusingitsproprietaryframework – the IIX Sustainability PyramidTM (Figure 28). The IIX Sustainability PyramidTM, marriesimpactcreationwiththefinancialhealthoftheenterpriseandassesseschangestooutcomesachieved.This analytical approach balances the social science need to demonstrate effectiveness with incisiveanalysis to improve social initiatives. The objective of the framework is to provide a valuable tool inhelping enterprises understand their impact value chain and identifyingways to deepen their impactcreation by analyzing its relevance to intended beneficiaries, the efficiency of this undertaking, theeffectiveness of its approach, and the viability of its impact creation over time. Additionally, theframework is designed to equip investors or funders to make an educated investment or capitalallocationdecisionsthatcanleadtooptimizedimpactgeneration.

FIGURE28:IIXSUSTAINABILITYPYRAMIDTM

TheToolkithasbeencustomizedforwomen'shealthintheUnitedStatesbasedonfindingsfromIIX'sfeasibility study to design theWomen's Health Bond to ensure the Toolkit takes a patient-centered

HealthcareEnterprise

PatientCenteredOutcomes

Access,Affordability,QualityEfficiency,Equity,Responsiveness

PatientCenteredOutcomes

(Quality,Affordability,AccessEquity,Efficiency,Responsiveness)

FinancialViability

SustainableImpact(Systemic/National/GlobalGoals)

Mission

E

HealthcareEntity


52

approachand isdesignedtomeasurehealthoutcomesthatmattermosttounderservedwomen.ThisapproachisfurtherdetailedintheIIXWomen’sHealthImpactAssessmentToolkit(guidelinesandexcelspreadsheet)thatwillbepublishedseparatelyandmadepubliclyavailablealongwiththisreport.

The Toolkit is comprised of 100 indicators: 60 generic indicators linked to access, affordability,efficiency, equity, quality and responsiveness and 40 condition-specific indicators linked to breastcancer,cervicalcancer,maternalhealthandreproductiverights–thefourfocusareasoftheWomen’sHealthBond.Sourcesfortheindicatorsincludeasystematicreviewandadaptationofmetricsfromthefollowing sources in addition to indicators shared by healthcare providers, practitioners and clinicsinterviewed:

• Agency for Healthcare Research andQuality(AHRQ)

• AmericanCancerSociety

• CentersforDiseaseControlandPrevention(CDC)

• CentersforMedicareandMedicaidServices(CMS)

• National Center for BiotechnologyInformation

• NationalQualityMetricsClearingHouse

• Network for Regional HealthcareImprovement

• Global Impact Investment Network (GIIN)IRISmetrics

• GuttmacherInstitute

• Healthcare Effectiveness Data andInformation Set (HEDIS) (under NationalCommitteeforQualityAssurance(NCQA))

• HenryJKaiserFamilyFoundation

• International Consortium of HealthOutcomesMeasurement(ICHOM)

• MaternalandChildHealthBureau

• OrchidHealthInternational

• Santilli&Vogenberg

• Saver&Martin

• TheCommonwealthFund

• TheLeapFrogGroup

• United Nations Sustainable DevelopmentGoals

• United States Agency for InternationalDevelopment (USAID) – MEASUREEvaluation

• US Department of Health and HumanSciences

• US National Library of Medicine (NationalInstitutesofHealth)

• WorldHealthOrganization(WHO)

EXPECTEDUSERSOFTHEIMPACTASSESSMENT(IA)TOOLKIT

IIXenvisionstheToolkittobeusedbytwomaingroups:

• Health care providers (demand-side of the capital equation): with the objective to improvepatient outcomes, increase healthworker productivity, enhance systemic efficiency, reduce costsandmobilizeadditionalcapital;and

• Funders or investors (supply-side of the capital equation): with the objective to benchmarkperformance,understandeffectiveness in termsofvalueofcare insteadofvolumeofcareand tomakemoreinformedcapitalallocationdecisions

KEYCHALLENGESIDENTIFIED

Sevenmainchallengesrelatedtomeasuringhealthoutcomeshavebeenidentifiedbasedoninterviewswithindustryexperts,healthcarepractitionersandpatientadvocates.Figure29providesabreakdownof the responses from interviews and surveys conducted as a part of the feasibility study (~60respondents).‘Lackofinclusionofpatientvoices/opinions'wasidentifiedasthemostsignificantbarrier,followedby‘focusonvolumeofcareinsteadofvalueofcare'and‘retrospectiveapproachtomeasuringresults'.


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FIGURE29:KEYCHALLENGESINMEASURINGIMPACTTHROUGHTHELENSOFIMPROVINGHEALTHCAREFORUNDERSERVEDWOMEN

WHBTOOLKITIMPACTMEASUREMENTAPPROACH

This section outlines the five-phase approach tomeasuring impact using the toolkit [Figure 30] thatseeks to address the aforementioned challenges by embedding the three IIX’s Women’s HealthPrinciples.

FIGURE30:FIVESTAGEPROCESSOFMEASURINGIMPACT

Phase1:DefiningScopeofUpfrontSocialDueDiligenceandStakeholderMapping

The first phase involves adopting a patient-centered approach from the onset of the impactassessmentinlinewithPrinciple1.Keyactivitiesinclude:

Lackofinclusionofpatientvoices/

opinions31%

Focusonvolumeorcareinsteadofvalue

ofcare24%

Retrospectiveapproachto

measuringresults17%

Limitedconsiderationof

socialdeterminantsofhealth

11%

Lowtransparencyandlow

accountability11%

Impactmeasurementviewedasacost-

center6%

Phase1 Phase2 Phase3 Phase4 Phase5

DefiningScopeofUpfrontSocialDueDiligenceandStakeholderMapping

UseIIXSustainabilityPyramidTMtoDetermineSocialValueGenerated

MobilizeCapitalBasedonEstimatedSocialReturnonInvestment

OngoingMeasurement,ReportingandAdaptiveManagement

ImpactVerificationwithPatientEngagementandSystematicReview

Principle1:Patient-Centered

Principle2:Proactive

Principle3:PositiveIncentives


54

• DefiningScopeofSocialDueDiligence:Itisimportanttodeterminethescopeoftheassessmentupfront (whether the assessment is for a single entity looking tomobilize additional capital or agroupofentities,agroupofinitiativesunderalargerumbrellaorganizationoronaspecificprogramrun by a single organization), the impact goals or priorities of the user (whether it is aninvestor/funderortheorganizationitself)andtheresourcesavailabletoconducttheassessment(toensureifwhatisbeingproposedisfeasible).

• StakeholderMapping:Stakeholdersaredefinedaspeopleororganizationsthatexperiencechangeas a result of thework of the entity being analyzed. In the case of this Toolkit, IIX recommendsprioritizing underserved women as the key stakeholder, particularly for outcomes such asaffordability, quality, and equity. Secondary stakeholders could include the entity/health careprovider or enabler themselves particularly for outcomes such as efficiency, responsiveness oraccess. IIXrecommendsonlyincludingstakeholdersthatexperiencematerialchangeasaresultoftheactivitiesoftheenterprise.

Phase2:UseIIXSustainabilityPyramidTMtoDetermineSocialValueGenerated

The next step involves using the IIX Sustainability Pyramid to determine the social value generatedusingaproactiveapproachtoestimatingfuturevaluegeneratedbasedonretrospectiveanalysisoftheentityinlinewithPrinciple2.Keyactivitiesinclude:

• Followingthestep-by-stepinstructionsintheprevioussectiontousethePyramidtodeterminethesocial value generated by the entity being analyzed. This includes data collection to create abaselineofsocialvaluegeneratedandthenusingaproactive,forward-lookingapproachtomeasureandprojectthechangetheentitywillmakeiftheyreceiveadditionalfunding.

• Atthisstage,usersshouldalsoassesshowmuchoftheentity’simpactisattributedtopreventionorearly detection as opposed to treatment. A cost-benefit analysis can be conducted to determinewhethermorecapitalisrequiredtosupportmoreproactiveinitiativesthatwillcreatelargerimpactorsavemorelivestoday(duetoprevention)and/orpotentiallysavelargercostoutlaysinthefuture(associatedwithtreatment).

Phase3:MobilizeCapitalBasedonEstimatedSocialReturnonInvestment

Thethirdphase involvesmobilizingcapitalbasedontheestimatedSROIorsocialvaluegeneratedbythecompany.TheobjectiveistoensuretheentityhasapositiveincentivetomeasureitsimpactinlinewithPrinciple3.Inadditiontodecidinghowmuchcapitaltoallocatetowardstheentity,therearetwootherfactorsthat investors/fundersshouldconsiderduringthisphasetounderstandhowcatalyticthecapitalprovidedisandhoweffectivelyitisbeingusedtomagnifyimpact:

• Leverage:The leveragefactorreferstohowmuchadditionalcapital isunlockedasaresultofthefundingprovided.Forexample,ifupfrontgrantfundingof$1,000,000isprovidedbyafoundationtostructureaBondthatthenmobilizes$100,000,000theleveragefactoris10X(forevery$1ofgrantcapital,$10ofinvestmentcapitalismobilized).


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• Additionality:Additionality is definedas theabilityof the capital tobring innewactors into theequation thatwould not have otherwise participated or to use the capital to fund initiatives thatwould not otherwise move forward at the required pace and scale to achieve a certain level ofimpact.Forexample,followingonthesamecaseasabove,iftheinvestorsintheBondareprivatesector, traditional investors instead of the foundation arm of a large bank, then there is greater‘additionality’becausetheseactorswouldnothaveotherwisefundedwomen’shealthwhereasthefoundationwouldhavelikelyprovidedthesameamountoffundingforasimilarpurposeanyway.

Phase4:OngoingMeasurement,ReportingandAdaptiveManagement

This phase recognizes the dynamic nature of impact assessments and suggests conducting proactivemeasurement,reportingandmanagementinlinewithPrinciple2.Keyactivitiesinclude:

• OngoingMeasurementandReporting:IIXrecommendsconductingongoingimpactmeasurementonaregularbasis.Whilethisistypicallydoneonaquarterlybasis,thefrequencycanbeadjustedbytheuserbasedonresourcesavailableandtheexpectednatureofchangecreatedbytheentitybeinganalyzed.Thiswillallowtheusertoproactivelyidentifyanydeviationfromprojections.InthecaseofinnovativefinancialmechanismssuchasBonds,IIXrecommendsprovidinginvestors/funderswithsemi-annualupdatesontheimpactperformance;highlightinganydeviationsfromprojectionsandsubsequentchangetheSROIforecastedwillensuretransparencyofresults.

• AdaptiveManagement:IIXrecommendsproactivelyaddressinganydeviationsfromresultstotaketherecommendedcourseofactiontoensuretheultimateoutcomesarestillmet.Assuch,usersareencouragedtoworkwiththeentitytoadapttheapproachasrequiredbytracingbackthroughtheimpactvaluechaindescribedinthePyramid.Theobjectiveofthisexercise istounderstandwhichactivities are causing the deviations and identifying how they can be re-adjusted in a feasiblemannertoensurethefinalsocialvaluegeneratedismaintainedasmuchaspossible.

Phase5:ImpactVerificationwithPatientEngagementandSystematicReview

Thefinalphaseinvolvesre-integratingthepatient’svoiceintotheequationthroughasystematicimpactverificationandreviewprocessinlinewithPrinciple1.Keyactivitiesinclude:

• ImpactVerification:Asapartoftheongoingreportingprocess,IIXrecommendsgoingbeyondself-reportingby theentityandengagingdirectlywith theendbeneficiary. In thecaseof thisToolkit,thiswouldentailconductingstakeholderinterviewswithunderservedwomentodetermine,intheiropinion, howmuch change (positive, negative, intentional, unintentional) has been experienced.Going forward, IIX recommends harnessing the power of technology to gather information anddigitalizing the impact assessment process to include the voice of the patients, which will bothfacilitatereal-timedatasharingintheimmediatetermandreducecostsinthelongterm.

• Systematic Review: Finally, users are encouraged to conduct a systematic review of the impactassessmentwith the entity receiving the funding at the end of the funding period. Thiswill helpsharelessonslearned,understandwhatworkedandwhatdidn’tandcreatemorepatient-centeredprogramsgoingforwardthatfocusonthevalueofcareinsteadofthevolumeofcare.

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