How results-based financing has strengthened England’s healthcare system

The Elton John AIDS Foundation has a long history as a grant-making organization committed to ensuring access to HIV care and ending the AIDS epidemic worldwide. The following case study describes the Foundation’s exploration of the enormous potential of results-based financing for HIV. The team began this journey by seeking to deeply understand the experience of people living with HIV. They were then pushed into new territory by creating and adapting innovative program design to those needs, securing external investment capital, developing iterative service interventions, and catalyzing national health policy change. to maintain long-term services. As the world’s first social impact bond for HIV, the successful model has substantial potential for learning and replication.

Unpacking the problem

The Foundation began this journey in 2015, more than three decades after the emergence of the HIV pandemic. the the number of people living with HIV in the UK was steadily increasing, and why existing services failed to curb new infections was unclear. Rapid and effective HIV tests were widely available. High quality treatment was free for everyone in the country. HIV medications could stop the progression of the virus and even prevent HIV transmission. The Foundation knew that stigma and discrimination have contributed to the spread of HIV around the worldbut they needed to understand the specific reasons for the spread in London.

The team started in the London Borough of Lambeth, an area where HIV rates 10 times higher than the national average. They conducted immersive ethnographic research to understand the real-life experiences and challenges faced by individuals in this borough. They interviewed HIV researchers, public health teams and implementation experts to get a sense of best practices. They visited local counseling centers and advocacy groups to hear from experienced community leaders. They even did guided tours, where the team experienced first-hand HIV testing in clinics or doctors’ offices. The most influential conversations were focus groups with Lambeth residents. This process provided the data needed to understand why people chose not to get tested for HIV (Box 1).

Box 1. Barriers to HIV testing


– Busy lives: “I work every hour trying to support my family. I don’t think about my health.

– Avoidance of health services: “My immigration status is uncertain. I try to keep my head down.”

– Discomfort with current testing options: “A general practitioner [doctor] would judge me.

– Absence of physical symptoms: “I feel fine. Why would I go to the doctor?


– Social stigma: “I would never discuss HIV with a hairdresser – all my neighbors would know.

– Early rejection: “I would be an outcast if I were HIV-positive.

– Self-stigma: “I am not that kind of person. »

– Belief that HIV means death: “It destroys entire families. There is no remedy. Why bother to test?

Source: Direct interviews and focus groups with Lambeth residents.

Identify a solution

The Foundation learned that practical barriers limit testing in clinics and social barriers limit community testing. HIV experts interviewed suggested a solution that could take testing to a new place: testing people for HIV when they present to hospital emergency rooms. In many cases, blood was already drawn, so an HIV test could be added quickly and inexpensively. HIV testing in emergency departments (ED) was already a formal recommendation advice from the National Institute of Health and Care Excellence (NICE)although not widespread, and an external ED test pilot in a neighboring district acceptable to patients and staff. It was time to bring HIV testing to the ER in south London.

The team swung into action, calling on National Health Service (NHS) leaders and other government officials to expand ED testing. Public leaders were supportive, but in meeting after meeting, no party had the money available to make it happen. It was clear that ED testing would pay for itself in the long run – with fewer people needing hospitalization for untreated advanced AIDS and fewer people contracting HIV in the first place – but these savings would take time to accrue. accumulate. Additionally, the savings would not all accrue to a single organization’s budget, but rather would be split among the city’s hospitals and clinics. This created a challenge for public health officials managing fixed and limited budgets.

Develop evidence in practice

Rather than trying to convince people to come up with a budget that didn’t exist, the Foundation decided to fund the program independently to create a proof of concept. The team sought advice from Social Finance, a leading impact finance nonprofit, on how they could use results-based finance to create a short-term program with a long-term impact. Together they designed a Social Impact Bond (SIB), a results-based payment mechanism that would allow investors to fund short-term services, with the intention that the government would cover the long-term costs if the program s proved effective.

As part of this SIB, the Foundation brought together an enthusiastic group of private and non-profit investors – ViiV Healthcare, Comic Relief and The Big Issue Invest – to cover the initial costs through a loan investment. They signed agreements with public and quasi-public payers – Lambeth Council and The National Lottery Community Fund – to reimburse investors as results were achieved. They met with service providers who could start testing and referring people to care. The new partners had varied areas of expertise, but they shared the mission of bringing HIV care to individuals. The “Zero HIV” SIB was implemented from December 2018 to December 2021, and during this period, 12 organizations in emergency departments, primary care offices, clinics and local communities provided new HIV services. HIV testing and engagement. Their tests and services have shown immense success, patient acceptability, and cost-effectiveness. (Box 2)

Box 2. Achievements of the SIB


– Brought over 460 people into HIV care, including 209 newly diagnosed and 256 re-engaged in care.

– Demonstrated that emergency testing finds underserved populations, with SIB patients that included 54% black, 35% women, and 10% aged 65 and older (compared to 2020 national averages of 24%, 29% and 4%, respectively).

– Demonstrated that those affected needed immediate help, with 75% having a late diagnosis (compared to the national rate of 42% in 2020).

– Cost-effectiveness assured, with ‘net healthcare costs averted’ of over £90m over the lifetime of those cared for and further transmissions averted.


– “The project really helped me because it made me realize that I was HIV positive. Without it, I never would have known.” – Person diagnosed and cared for

– “Push the tests. … Tell them my story, the encouragement will save lives and unnecessary suffering. – Person diagnosed and treated

– “The ripple effect of SIB has begun to challenge the stigma associated with HIV among staff and patients.” – Clinical nurse specialist

Sources: Zero HIV Social Impact Bond internal data. Independent analysis of avoided costs. National HIV data. Testimonials from patients and providers.

Changing national health policy

As the SIB progressed, project partners increasingly codified and shared emerging positive results. The Foundation worked with the National AIDS Trust and the Terrence Higgins Trust to launch an independent commission on HIV, which developed a comprehensive report on recommendations to end HIV in England by 2030. The results of the SIB were highlighted at the launch of the report, and as the government began to integrate the report into its own plans, it continued to build on the learnings of the SIB.

The SIB has enabled the Foundation to advocate for emergency HIV testing with concrete evidence of its success and cost-effectiveness. On December 1, 2021, one month before the conclusion of the SIB, the the government has allocated £20million to roll out ED testing nationwide to all local high prevalence areas. Scaling up this approach will mean essential testing for people in need across the country, especially those who would have been hesitant to get tested at sexual health clinics or doctors’ offices. Although the SIB has come to an end, the national NHS rollout will pick up where it left off and expand the great work.

Extend the model

Emergency room testing has proven to be an extremely effective intervention for reaching people who otherwise would not have received HIV testing or care. However, knowledge of the intervention alone was not enough to bring about long-term change. This SIB has enabled the program to leverage funding from independent investors, deliver innovative health services, build a strong case with clear evidence, and deeply engage public and private stakeholders throughout the process. This laid the perfect foundation for an eventual transition from SIB pilot project service delivery to government implementation.

Lessons learned from this SIB could be extended to other pay-for-success and results-based models. This project went beyond pure social impact bond model developed in 2010, offering variation in the types of stakeholders involved and the mechanisms through which funds flow. For example, this design could be applied in the United States where it would be difficult to do a traditional SIB with local government, as many parties have the responsibility to pay for HIV testing and care services. Private insurers and managed care organizations can be particularly helpful partners in this context, especially those that have demonstrated a commitment to addressing health equity and the social determinants of health.

As the Foundation and others move forward with replication, the Zero HIV SIB experience shows the importance of putting the problem first, carefully tailoring services, and selecting a program model and partners for long-lasting, lasting impact.

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