Canada’s Activate program is an excellent example of how social impact bonds can be used to finance health promotion and disease prevention programs. To learn more about social impact bonds, read social impact financing.
Without intervention, half of all pre-hypertensive people over 60 in Canada will develop hypertension within 4 years. Heart disease & stroke are leading causes of death, taking the lives of more than 66,000 Canadians every year, and hypertension is the number one risk for stroke and leading risk factor for heart disease. The Activate program was designed to prevent the onset of high blood pressure among older adults. Activate’s participants are members of the general public that are pre-hypertensive, not diabetic, not on blood pressure medication, and at least the age of 40.
Besides its health promoting purpose, the Activate program is an opportunity to assess the impact of preventative health measures on hypertension. The target for success was set by cardiologists at no increase in blood pressure readings, although an overall decrease is even more desirable.
Key stakeholders in the Heart & Stroke Activate program are the Heart & Stroke Foundation of Canada, Canada’s Public Health Agency, the Social Research and Demonstration Corporation (SRDC), and the MaRS Centre for Impact Investing and Investors.
Using social impact bonds to attract investors
The Activate program was developed in collaboration between the Heart & Stroke Foundation of Canada and MaRS Centre for Impact Investing. Under the agreement, the Heart & Stroke Foundation is responsible the overall development and execution of Activate under the advisory of the MaRS Centre for Impact Investing. The SRDC serves as a third-party data validator and external evaluator of key program metrics.
Funding for Activate comes from a pay-for-success (PFS) model, or social impact bond (SIB). Working closely with the MaRS Centre for Impact Investing, Heart & Stroke has attracted philanthropically minded private investors to provide upfront capital. The federal government, through the Public Health Agency of Canada, repays the investors based on successful outcomes. This is only the second time in Canada that this funding model has been used, and the first time for a large-scale chronic disease prevention initiative.
The program is implemented in collaboration with external partners such as NexJ Health, Loblaws / Shoppers Drug Mart, Loblaws and YMCA.
- NexJ Health manages the digital health platform that participants use.
- University of Ottawa Heart Institute also provided the health coaching protocol for participants in the Activate program, which they deliver in partnership with NexJ Health.
- Shoppers Drug Mart, Loblaw’s, and YMCA locations are being leveraged as public recruitment locations.
- Shoppers Drug Mart, Loblaw, and YMCA also provide key services for participants in the program including operational and program support.
- The YMCA has provided free 2-month memberships to all Activate participants and co-developed in-person community days.
The program is financed through a social impact bond (SIB) that follows a pay-for-success framework. In other words, investors make payments to the Heart & Stroke Foundation of Canada to execute and run the Activate program. Depending on outcomes of the program, primarily volume of participants and overall change in blood pressure, the Heart & Stroke Foundation receives payments from the Public Health Agency of Canada, which are then paid out to investors. The investors get paid after the recruitment phase of each cohort based on volume, as well as a final payment based on blood pressure reading. We cannot be certain of the exact return until after the program as it based on the overall outcomes for blood pressure and volume.
While the funds come from the federal government, the outcome payments were not negotiated to come out of an existing fund for services (e.g., hospitals). The federal government stepped in and drove it forward through their innovation agenda. They saw the value in the scalability and opportunity for impact. In Canada, the large portion of the health spending is provincial while preventative funding comes from the federal level.
The Activate program has primarily 3 mechanisms that assure the quality of delivery of the program:
- The Activate program is tied to the outcomes of the social impact bond. The program has volume targets, which is the number of participants enrolled in the program over the course of 3 years as well as blood pressure change targets.
- The volume target is enrolment of 7,000 pre-hypertensive adults in Toronto and Vancouver.
- The BP target is to halt the increase in blood pressure between the time of intake and follow-up after 6 months of being in the program.
- The outcome payments are based on the achievement of these targets. If targets are achieved, then investors stand to break-even on their investment.
- The Activate program is overseen by a project board made up of key stakeholders in the program. The project board receives weekly e-mails from the Activate team and bi-monthly meetings are conducted to ensure that milestones are being met and the project is on track.
- Finally, all data collected through the Activate program is evaluated and validated by SRDC, a third party. Every year, SRDC validates both the volume and blood pressure outcomes of the program before the outcome payments are issued.
Currently, the Activate program has completed evaluation for the first year of the program and has exceeded both volume and blood pressure targets. In the first year of the program 527 hypertensive adults were enrolled into the program, exceeding the volume target of 500, and the average change in blood pressure was -5 mmHg systolic, exceeding the target of a flattened blood pressure trajectory over the course of 6 months.