What am I actually doing here?
Well, about a year ago I found out about an amazing sounding project called YBank. A few emails and Skype calls later, I’ve ended up in Kigali, attempting to get the first pilot study underway.
YBank was founded in 2014 at the Harvard School of Public Health, by three residents at the Harvard Innovation Lab passionate about adolescent health, behavioral economics and human centered design.
Read more here: http://www.y-bank.org/#ybank
The study in Rwanda is focused around the issue of adherence to ART (anti retro-viral therapy) amongst adolescents living with HIV.
Although HIV-related mortality in general is falling, amongst adolescents HIV-related mortality actually increased by 30% between 2005 and 2013.
Previous research has shown that these poor outcomes are being driven by lack of adherence to ART and loss to follow-up amongst adolescents compared to other age groups. Moreover, a recent study in Rwanda revealed socioeconomic factors (i.e. if you come from a family living on less than $1 a day) present the most significant barriers to adherence.
YBank are working with the University of Kigali to address this challenge using three key components:
Using the power of financial savings and inclusion to motivate healthy choices.
Teens helping teens through peer mentoring to stick to their medications and stay well.
Provide young people with the skills to invest their savings and plan their future livelihoods.
There are several really interesting facets to this project –
Firstly, adolescent health is now widely recognized as a pressing global health issue. Teenagers will grow up to be the future parents, professionals & workforce of the future. If we don’t invest in adolescent health now, there is both a healthcare crisis and an economic disaster waiting to happen. Adolescents living with HIV are an especially pertinent example of this. Although the majority are currently healthy, poor adherence over time leads to disastrous health consequences for the individual, leading to repeated hospitalisations and the inability to work, thus creating severe economic difficulty for them, their families and society as a whole. Furthermore, the risk of onwards transmission in this population remains high – poor adherence leads to a non-suppressed viral load, and at a time when many are engaging in the high-risk behaviours (including unprotected sex) typical of adolescence in any setting, well…you can imagine the consequences.
If you want to read more about global adolescent health, the behavioural and cognitive changes that occur during adolescence, and the challenges this creates, this is an excellent article (free from the Lancet) by Prof. Susan Sawyer: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)60072-5.pdf
Secondly, the idea of cash incentives is being used more and more to promote healthy life choices – although it is a controversial issue and one which generates plenty of debate! There is some very interesting behavioral economic theory which underpins the concept – namely that by helping to promote financial inclusion (i.e. the process of opening a bank account and the idea of generating savings) and lifting an individual’s socioeconomic status, they start to value themselves and their role in society more, and hence start to make healthier life choices. Furthermore, we know that the teenage brain is particularly sensitive to ‘rewards’, and therefore the use of even very small sums of money (for example, mobile phone credit) could be a novel and very effective motivational tool. This is an entirely new area to me, so watch this space for more information/research and thoughts on the matter as I try to catch up on all my reading!
Finally, from a development point of view, I am learning all about the new (and potentially exciting) world of ‘DIBs’ – development impact bonds. In an era in which not only is foreign aid decreasing, but the way in which we think about ‘aid’ is changing dramatically (does it do more damage than good?…probably, yes) with much more of a focus on local ownership, long-term sustainability, and impact, the way in which non-profit projects such as this one are funded will also change. Development impact bonds are similar to Social impact bonds – in very simple terms, it goes something like this:
- Government identifies an issue (e.g. non-adherence amongst adolescents)
- Private investors provide funds upfront (e.g. private philanthropic foundation)
- Intermediary (e.g. NGO) implements programme to deliver an agreed outcome (e.g. 100% adolescents to have suppressed viral load in 5 years, or 95% of rural schoolchildren to have achieved basic literacy by the age of 10)
- If the programme is successful and the agreed outcomes are delivered, the government then pays back the private investor.
- If the outcomes are not delivered – the government does not pay anything back and the investor loses their money (although there is the potential to have a ‘guarantor’ in the equation who can pay back the investor).
It’s obviously far more complex than that, and again a concept which I am still trying to learn about and understand. But, in principle, it provides a way to transfer financial risk away from the public sector (the government) across to the private sector. It also means that the intermediary is tasked with delivering specific outcomes, and proving that the project they intend on implementing actually works. Finally, it generates the possibility of sustainability, because assuming that the project is proved to be a successful, the government can then take on responsibility for continued funding, safe in the knowledge that they are spending public money on a tried and tested program that can deliver the outcomes they need.
As yet, no DIB has been successfully implemented…so we’ll see how it goes; would welcome any advice from those with more economics knowledge than me!
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