A small-scale 'Development Impact Bond' for hepatitis C diagnosis and treatment financing in Cameroon: the way to elimination?

Abstract

# Background Many governments in low- and middle-income countries (LMICs) have difficulties paying healthcare costs upfront leading to high out-of-pocket payments for patients. A Development Impact Bond (DIB) is an innovative financing mechanism in which pr ivate investors provide pre-payment of development program expenses. At the same time, public agencies or donors repay the investor's investment with a reasonable interest rate if the program succeeds in delivering independently measurable results that are contractually agreed upon. This study assessed quantitatively and qualitatively the feasibility of a DIB for hepatitis C Virus (HCV) diagnosis and treatment in Cameroon. # Methods A revolving fund of up to €230,000 was made available by the investor. The outcome payor reimbursed the investor only in case of good performance, defined as cured patients (HCV-RNA negative). HCV carriers who were identified were referred for treatment and tested for cure 12 weeks after completion of treatment, the outcome being validated by an independent assessor. The evaluation was guided by the six-agents model, involving interviews with relevant stakeholders (N= 22). # Results In total, 253 (98%) patients completed treatment, of which 244 (96%) are cured at week 24. We estimated that the average per-patient *outcome payment* for HCV diagnosis and treatment is €1,542, and the *average costs per treated patient* is €1,858. The investor was fully repaid, including the agreed interest and bonus. Themes or findings from the interviews confirmed the feasibility of a DIB in a low-resource setting. # Conclusions This study demonstrates that a DIB can be a suitable financing mechanism for HCV services, supporting the path towards elimination. When governments in LMICs do not have sufficient resources to fund such elimination programs upfront, such public-private partnerships can offer a solution.