SIBs may provide components for outcome-based contracting, but they are not a panacea


Public service reform can benefit from outcome-focussed approaches to commissioning. However, we should avoid assuming that Social Impact Bonds are likely to have wide application, explain PIRU’s research team.

Social Impact Bonds (SIBs) are likely to become just one part of the search among policy makers, practitioners and researchers for viable approaches to outcomes-based commissioning of public services. That’s what we conclude in our assessment of the SIBs Trailblazers in health and social care in England, set out in our recent report. Here we reflect on a number of issues raised in our own research and by previous blogs in the PIRU series on SIBs.

Testing, as yet unproven, outcome-based models of commissioning is important for public services, which are often clear about their goals but hamstrung by inadequate implementation including unsupportive funding mechanisms. In health policy, for example, there is a goal to develop healthier citizens – not just to treat more sick people. Reaching that goal could reconcile the ambition to provide better health care with the need to control budgets. However, how can health and social care – and the other parts of the public sector – work together to achieve such goals? We lack a tried and trusted mechanism.

Focus on outcomes-based funding
In this light, the focus that SIBs provide on developing outcomes-based approaches to commissioning services is welcome. SIBs in health and social care have the potential to break through institutional inertia and generate innovations in public service delivery. At best, they can free and motivate front-line service provider staff to focus strongly on the needs and desired outcomes of their clients.

One of the issues holding back public service innovation, particularly in the last decade, has been a lack of funding for prevention as the demands of those currently in need of support have become ever more pressing. Amid austerity and lack of time for contract management, commissioners have found it difficult to think strategically. In this context, SIBs have been welcomed by policy-makers, commissioners and providers, drawn by the promise of upfront funds to develop services designed to improve outcomes in the longer term.

Issues with SIB upfront funds
What’s not to like about that promise? We have two caveats. Some Third Sector organisations lack the capacity to monitor user outcomes well and thus to demonstrate accountability for the upfront funding that they receive. Thus, upfront funding needs to be used not just for service delivery, but also for developing capacity at the provider level in areas such as outcomes measurement and data management.

A second – and perhaps more fundamental – concern about SIBs’ provision of upfront funds is whether this is an efficient way to generate extra cash. The injection of more funds can be seen as a good thing per se, but, it brings with it two further problems.

First, investors are often risk-averse, which can get in the way of innovation, a raison d’être for SIBs and for outcomes-based funding in general. There may also be clashes between the values of private investors and those of the ultimate payer for results – the public commissioner on behalf of the public/tax payer. Additionally, there may be adverse impacts on Third Sector staff’s motivation if the pursuit of specific outcomes is prioritised ahead of meeting the specific needs of individual clients.

Second, many SIBs are set up with the help of intermediary organisations which can add to their cost. As a result, these costs have to be set against the value of any client outcome improvements. The activities of such intermediaries may also inhibit capacity building at the provider level if they assume long-term project management and monitoring roles.

Need for experiments to stretch the SIB model
Ultimately, the public purse foots the bill for SIBs, even if this only takes place after the successful delivery of agreed outcome improvements. Yet, there may well be other more efficient approaches to outcomes funding. We may need to have experiments that stretch the already flexible SIB model and compare it with other approaches. So, for example, Big Society Capital, the Big Lottery Fund, or other socially minded investors could experiment with conditional grants, rooted in outcomes-based contracts, to spur innovation in service delivery, and compare these with SIBs. In her contribution to this blog series, Katy Pillai, Investment Director at Big Issue Invest, signalled that investors are keen to support research into what works best in this regard.

In our experience, most up-front SIB finance does not come from business investors. It comes from philanthropic investors, alongside central government sources such as the Life Chances Fund. For example, the eventual outcomes payments made to investors in the Trailblazer SIBs which we studied were mostly paid for by tax-funded public commissioners upon delivery of the service. Upfront philanthropic funds (investors) were useful and the Big Lottery (which provides a quasi-governmental subsidy for outcome payments) helped to fund the additional effort needed for commissioners to consider and experiment with outcomes payments.

Given how SIBs are largely working this way in practice, would it be wise to experiment with a different SIB model that removes the commercial imperative altogether? This SIB model is, in ways, a variant on the experiments suggested above for socially-minded investors such as Big Society Capital and the Big Lottery Fund. It could amount essentially to organising forgivable loans to Third Sector providers from philanthropic agents, alongside dedicated contract and performance management support. Such an approach would remove the financial architecture of ‘investment’ that surrounds SIBs at the moment but could reduce their transaction costs and accelerate the innovation process.

Clarify values of outcome-based contracting
A big issue when discussing SIBs – or any form of outcome-based funding – is to define their purpose. Are they simply about driving efficiency and making savings to the public purse or are they about transforming the social value of services? Are they a tool to create better monitoring and evaluation cultures in non-profit organisations, so improving accountability and value for money? What are the values being prioritised in such contracts? Thinking and practice in the Asia Pacific region, discussed in the blog by Chih Hoong Sin and Ichiro Tsukamoto, focussed, for example, on a further role for SIBs in transforming the relationship between civic society and the State.

What PIRU and other research has found
So far at least, it has not generally been possible to show that SIBs have produced cashable savings to the public purse. Globally, the main demonstrable success of SIB projects has been in helping marginalised groups that had previously been badly neglected by public services. Here, there was often a baseline of little or no provision, so it was highly likely that anything would have helped in such circumstances. In areas with some previous provision, it is less clear that SIB-funded services, for example, for people with chronic health conditions, have led to superior improvements in health.

Next Steps
The general argument, in principle, for developing outcome-based commissioning and contracting is strong, given the difficulties that policy makers have in matching their goals with the limited funding mechanisms currently available to them. However, we are some distance from resolving all the difficulties in making an outcomes-focus work in public service commissioning and in establishing the case for applying these approaches at scale. So, it is wise to experiment widely and to keep learning.

In this light, policy makers should focus on the components within SIBs that show promise in strengthening outcome-based contracting, while avoiding the notion that the whole package offered by a SIB is necessarily the way forward. SIBs, as currently conceived, may have some dedicated roles, but these are likely to be in particular circumstances (for instance, when outcomes are relatively easy to measure and relatively uncontroversial). The greater value of SIBs and related thinking, in the long run, may be in informing the wider development of other models of outcome-based contracting for mainstream service delivery rather than in replacing these approaches.

Stefanie Tan and Alec Fraser are Research Fellows at the London School of Hygiene & Tropical Medicine and part of the Policy Innovation Research Unit (PIRU) at LSHTM.

Nicholas Mays is Professor of Health Policy at LSHTM and Director of PIRU.

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30 August – 5 September 2018

Martin McKee provides comment to the Guardian on news that the Medicines and Healthcare products Regulatory Agency (MHRA) has lost contracts assessing medicines for the European Medicines Agency (EMA) as a result of Brexit. Martin said: “The MHRA has benefited enormously from its close links with the EMA. The fracturing of those links will impact severely on its budget, much now from the EMA, and its ability to attract and retain skilled staff.”

Martin also comments in OnMedica about new research published in the European Heart Journal, which reports a correlation between smoking and alcohol in teenage years and vascular damage. Martin said: “This paper highlights the importance of examining the combined effects of exposure to agents that act through different mechanisms on the cardiovascular system as the adverse effects are likely to be greater than with either on its own.”

Sanjay Kinra co-authors new research covered in Times of India which finds that one out of every 10 students of Delhi’s private schools suffer from obesity, high blood pressure and increased levels of bad cholesterol. Authors say: “this is the first research to report on the distribution of multiple risk factors for NCDs in school students in India, comparing low socio-economic status to high socio-economic status.”

Naomi Stewart authors a blog for London International Development Centre about drug resistant tuberculosis in South Africa and explores the Umoya omuhle project, which is working to develop a health systems intervention that can help stop new infections.

On social media

This week’s social media highlight tweeted from @LSHTM is an expert opinion piece by Joe Tucker and Jason Ong looking at whether crowdsourcing could be a catalyst for increasing HIV testing in China.

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Collection of the Month – Sir Shirley Murphy

September’s collection of the month features the collection of Sir Shirley Foster Murphy.

Sir Shirley Foster Murphy was born in 1848 and educated University College School and Guy’s Hospital. His work included being the Vice President of Royal Sanitary Institute, and was involved in a range of societies and organisations including; Society of Medical Officers of Health, Epidemiological Section Royal Society of Medicine and Royal Statistical Society and examiner in Public Health, Royal Colleges of Physicians and Surgeons.

He was a Bissett Hawkins Medallist, Royal College of Physicians; Jenner Medallist, Royal Society of Medicine; Medical Officer of Health, Administrative County of London and a member of Royal Commission on Tuberculosis. Murphy was knighted in 1904; awarded Knight Commander Order of the British Empire, 1919, and became a fellow of the Royal College of Surgeons. He died in 1923.

His collection is fascinating and nearly unique within the LSHTM collections, with a large focus on the history of the slaughter of meat for food, and later the slaughterhouses in Europe in the late 1800s – early 1900s; including the efforts taken to better sanitise them.

Slaughterhouses as a form have been around for centuries. What is later referred to as a ‘public slaughterhouse’ has origins at a minimum in ancient Rome, where before 300BC, animals were slaughtered in the Forum in the open air, and as time went on (to meet the convenience of butchers) animals were slaughtered near the River Tiber. These forms of slaughterhouses existed in the UK as well, at least until the Public Health Act of 1875.

”What adminstrative measures are necessary for preventing the sale to the public of tuberculous meat” GB 0809 Murphy/05

The Public Health Act of 1875 changed the development of slaughterhouses, which until then had been very loosely regulated. The concern about better regulation within slaughterhouses became a matter for public health, as there was evidence of disease (most concerning was Tuberculosis) within the meat that killed for the purpose of human consumption. Private slaughterhouses become more common in England after the passing of the Public Health Act in 1875, and these slaughterhouses were licensed annually by a local authority. Private slaughterhouses that existed prior to this act are registered but did not have to be subject to the annual licensing. While some sanitary authorities enforced bylaws and regulations regarding sanitation of slaughterhouses, this was not widespread.

Slaughterhouses were of two types; private (belonging to individual butchers) and public which are for communities (for example, in large towns). In the early 1800s in England, the power to provide public slaughterhouses had been given to municipal corporations, but was sparingly used. In the 1875 Public Health Act this power was extended to include all urban authorities as well.

A petition of the Committee of the London Central Meat and Poultry Markets Association to the County Council of the Administrative County of London GB 0809 Murphy/02

In England, often public slaughterhouses were called abattoirs, to differentiate them from the butcher’s associated slaughterhouse. This association created tension during proposals to only allow the slaughter of animals in such public slaughterhouses as opposed to those run by the butchers.

In London, there were disagreements between the County Council and The Committee of the London Central Meat and Poultry Markets Association, of which the latter wrote to the Council outlining some key points as to why the proposal to close down private slaughterhouses out of concern of a lack of meat inspection was a bad idea. They propose that they are not at all adverse to proper meat inspection and that the private slaughterhouses serve a purpose within their community, through supplying meat for food.

An example of the responses of the Committee of the London Central Meat and Poultry Markets Association within the petition. GB 0809 Murphy/02

Murphy challenged many of their points, maintaining that in order to prevent the sale of tuberculous meat, the slaughter of all animals intended for consumption should be in public slaughterhouses and that competent meat inspections are employed.

In England the meat inspection differed from the rest of Europe, as the butcher was the one to inspect the meat to determine whether it was fit for human consumption, as he was presumed to have sufficient knowledge for that purpose. While other counties employed a systematic meat inspection by the local authority. This was seen by Murphy as being the preferred method, referring to Copenhagen for example, who used a stamping system for meat butchered of first class which was ‘quite sound’ and second class which would be fit for consumption after cooking.

Handwritten notes reporting the inspection of meat in Berlin. GB 0809 Murphy/02

All other meat that did not make the 1st or 2nd class stamp would be destroyed through burning. Murphy hoped to bring the practices of continental Europe to England to allow for safer meat.

To access this unusual collection, contact us at  to book an appointment.



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Persson, Breastfeeding PLOS Med 2018 journal.pmed.1002646

Breastfeeding in low-resource settings: Nota a “small matter”

The evidence is clear – breastfeeding has positive health effects both for mother and child. In an editorial published in PLOS Medicine Professor Lars Åke Persson summarises some of the most striking reasons for babies to be breast-fed within the first hour, exclusively within the first six months and continued during the second year of life. Health benefits include lower morbidity and mortality rates, as well as better neuro-cognitive functions. For mothers who breastfeed reduced risk of cancer is cited. Why then is breastfeeding not the social norm around the world? Professor Persson explains that an enabling environment, at societal level, within the health system, at the workplace and in families, is necessary for more babies to be breastfed.

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The politics of alcohol and policy formulation

By Adam Bertscher, Leslie London & Marsha Orgill (all authors University of Cape Town)

Alcohol is contributing to a growing global burden of non-communicable diseases. Some of these diseases are referred to as ‘industrial epidemics’ because they are the result of social or commercial determinants of health. In other words, they are – at least in part – a result of the activities of business practices who aim to sell their products on mass.

A global health priority

Alcohol is recognized as a global health priority and a call to strengthen global and national alcohol control policies has been made – however health is political and drafting policies can often take years because multiple actors with power and vested interests may influence the process. Alcohol policy is particularly political because economic arguments and public health arguments are often at loggerheads.

Recognising that alcohol is a major public health burden and cost in South Africa – and that alcohol advertising often targets young people and encourages underage drinking – the South African Department of Health developed the 2013 draft Control of Marketing of Alcoholic Beverages Bill to restrict alcohol advertising as an evidence-based upstream intervention. The Bill has been subjected to repeated impact assessments and, 5 years on, has not been released for comment.  Through the research we sought to shed light on the politics of policy formulation and in our Health Policy and Planning paper we discuss a number of factors at play in the complex policy formulation process:

  • There was an explicit use of economic arguments by industry representatives to counter public health arguments – and these economic arguments were disseminated more widely than public health arguments in the media, even though the research underlying the economic arguments was called into question
  • The alcohol industry uses perception strategies to frame solutions to the alcohol problem, actively portraying the industry as a partner of government and proposing corporate social responsibility and public-private partnerships as solutions to alcohol-related harms
  • The current silo model of government departments contradicts the Health in All Policies approach – government departments have concerns and interests not always aligned with public health
  • Stakeholder consultative platforms are actively used by the alcohol industry to promote their message
  • Two of the three impact assessments conducted in the process of considering the law were not put in the public domain for scrutiny

These results raise critical issues that should be considered:

  1. Governments need to institutionalise appropriate governance structures to ensure a Health in all Policies approach
  2. What is the role of regulatory Impact Assessments (RIAs) and/or Socio-economic impact assessments (SEIAS) in the policy formulation process if they are not made public? – who owns this process and the subsequent results?
  3. What is the role of the media in public health in either promoting or undermining public health goals?
  4. What constitutes ‘stakeholder consultation’ and what power does this give rise to?

Finally, with the growing push for public-private partnerships (PPPs) as a panacea to global problems, we must always question and investigate through research who stands to benefit from these PPPs and who is bearing the cost of the alcohol industry and alcohol-related harms in societies.

You can access the full Editor’s choice article in Health Policy and PlanningUnpacking policy formulation and industry influence: the case of the draft control of marketing of alcoholic beverages bill in South Africa.

Creative Commons outside of Academia

Authors at LSHTM will know that, when making work Gold Open Access, they need to ensure that they publish their work with a CC BY (Attribution) licence. This allows anyone to 1) copy, distribute and transmit work, 2) adapt work, and 3) make commercial use of the work under the condition that the user must attribute the work in the manner specified by the author or licensor. This blog post aims to explore what ways the Creative Commons licences, (of which CC BY-after CC0-is the most liberal), has been used and built upon by the community beyond academia.

Some of the projects found were film festivals, like CCWorld (Media Commons Network), a network of festivals from all over the world, which aims to share, extend and promote audio-visual works that follow openness and free culture criteria, music projects, and catalogues of symbols. Here is an introductory illustration of some of these.


In addition to the film, The Internet’s Own Boy: The Story of Aaron Swartz (2014), shown at last year’s LSHTM Open Access week, there is a collection of films, all available under a Creative Commons licence available to watch and screen for free from CCWorld’s webpage here:

The group that maintain this collection and initiate this network are a collective in Barcelona who run an annual festival for films licensed with Creative Commons, and put at the disposal of anyone interested all the materials generated in the realisation of its own festival, The BccN Barcelona Creative Commons Film Festival.

Included in this collection is a full-length film about Pirate Bay, a file sharing service that infringed copyright by providing links to thousands of songs, films, video games and other material, and helping users download them. The film ‘The Pirate Bay Away From Keyboard’ (2013) was released under a CC BY NC ND licence, and therefore available to share, as long as for non-commercial (NC: Non Commercial) purposes and as long as no modifications were made to the material are distributed (ND: No Derivatives).


Musicians have long utilised Creative Commons licences (which are the same licences encouraged by funders like the Wellcome Trust and UK Councils in relation to research outputs), for instance:

Nine Inch Nails

The band Nine Inch Nails (NIN) released two albums under Creative Commons licences: Ghosts I-IV, a 36 track instrumental collection with only numbers as titles to the tracks and The Slip, which was also made available without any prior notice under a CC BY NC SA licence.

NIN harnessed the potential for experimentation that these licences harbour by calling for user-generated music videos to make a Film Festival to coincide with the music from Ghosts I-IV. The frontman Trent Reznor introduces the project here, and there were extensive submissions responding to this call for experimentation.



ccMixter is a site for music lovers, producers, singers, sound designers and songwriters featuring remixes and samples licensed under Creative Commons licenses. Users are free to download and sample from music on this site and share the results with anyone, anywhere, anytime.

The University of Utah’s School of Medicine, Music and Business collaborated with ccMixter on a “Music for Healing” project that facilitates the creation of a new collection of music that focuses on healing and supporting patients and their families, focusing specifically on Alzheimer’s, Dementia, Autism and Epilepsy.

Users can search for sounds by genre, instrument and style on the discovery site digccMixter, where everything is also under a Creative Commons licence that makes their reuse free. diggccMixter, which was founded by Creative Commons, compiled a Mixtape to celebrate the tenth anniversary of their sharing tools.

Inspired by ccMixter, Wired Magazine released The WIRED CD: Rip. Sample. Mash. Share. They accompanied this with a great piece that can be read here too.

The Free Music Archive is another fantastic music discovery tool, where searchers can filter by licence types so they know how tracks can be used.

Learning (Languages)

Finally, alongside for profit tools like Duolingo, people can access a wide variety of resources that either are in the public domain, or liberally licenced with Creative Commons licences, to aid their language learning free:

  1. Deutsch im Blick is an open access site with free and open multimedia resources, which requires neither password nor fees and featuring a free online textbook for learning German from the University of Texas. It is the web-based first-year German program developed and in use at the university.
  2. The courses of US Foreign Service Institute (FSI), who teach foreign languages to government diplomats and personnel for duties abroad, are in the public domain. Here is the audio and the text for basic German, for example.
  3. IRIS is a useful is a digital repository of instruments and materials for research into second languages.

FORCE 2018/LSHTM Open Access October

I will present this blog, as a poster, at this year’s FORCE 2018 Conference at McGill University in Montreal, Canada thanks to generous funding from the UCISA bursary scheme 2018. This conference, for which the theme is ‘engagement’, will take place during October, when LSHTM’s Open Access Team will be hosting a series of open access events.



Blog from Dr Priya Morjaria: Co-Lead Educator for Global Blindness: Planning for Eye Care Services MOOC

School children in India

Dr Priya Morjaria, Co-Lead Educator

For the past 3 years, I have been working on my PhD at the London School of Hygiene and Tropical Medicine. The focus of my work was ‘Evidence to improve the Efficiency and Effectiveness of School Eye Health Programmes’.  The work has taken me all over the world, from Botswana to Malawi to Nepal to the Philippines and China to get an understanding of school eye health programmes. I undertook two clinical trials in India both with the primary outcome of increasing spectacle compliance. While there were many lessons and the process of setting up the two trials brought not only academic learning, but also experiences, that have helped to understand the reality of setting up a comprehensive school eye health programme. And their impact on the lives of children.

A very vivid memory I have from my time spent screening in the schools in India was of a child who had her first vision check at the age of 12. She had stopped coming to school regularly for the past few years and was in the day we were screening vision to identify those children that had a visual impairment. She was seeing less than 6/120 in both eyes. We refracted her and her vision improved to 6/9. She had not used spectacles previously and was overwhelmed with her clear vision. I am convinced my experience is not unique and there are many who work in eye care who have such stories to share and are affected by these incidents. It reminds us the importance of school eye health programmes and the need to implement programmes in a systematic way.

Setting up a comprehensive school eye health programmes does not end with screening and diagnosing. It is crucial that treatment and follow-up of adherence to treatment is a part of the programme. Hence, every programme should include monitoring and evaluation and this aspect be budgeted for.

This course will give an overview of the principles in planning and managing an eye care programme and how the different principles can be applied to different eye conditions. It is a brilliant course for both those who are new to the field of eye care and to those who already work in eye care and want to refresh their skills and knowledge base.

I look forward to interacting with all of you on the course and am excited to be a co-educator. I did my MSc in Public Health for Eye Care at the London School of Hygiene and Tropical Medicine and continued as a researcher at the school, working on various projects in global eye health. I recently completed my PhD at the school and was on of the first cohorts to do the Global Blindness course on FutureLearn and it is very exciting to be a co-educator on it now.

On Monday 3 September 2018 – join Dr Priya Morjaria and take the course! Register here:

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23 – 29 August 2018

Heidi Larson provides comment to Newsweek and the Daily Mail on a new study that reveals the extent of misinformation on vaccines spread by ‘bots’ on social media. Speaking to Newsweek, Heidi said: “[The study] should wake up the public to being more critical of the comments they’re reading online.”

Heidi is also quoted in The Economist (£) on how a rising anti-vaccination sentiment in Europe could be linked to the record number of measles cases in the region.

Rachel Lowe speaks to The Guardian on the growing threat of European tropical disease outbreaks linked to rising temperatures due to climate change: “Mosquitos thrive in humid conditions and rainfall can increase breeding sites. But something we found is that drought conditions can also increase breeding, because of the ways people store water.”

Jimmy Whitworth is quoted by CNN after a case of MERS virus is confirmed in England – the first in five years: “MERS-CoV is a disease we worry about because we don’t have any specific countermeasures to it. We’ve got no specific drugs, no specific vaccine, or anything to deal with it. Essentially we need to identify cases, get them into isolation and to give them intensive supportive care until they get better.”

Mishal Khan, Sonia Rego and Julia Spencer write for BMJ blogs on how prescription-only access to antibiotics could exacerbate health inequalities in LMICs.

Laurie Denyer Willis is interviewed by Cultural Anthropology on how in Rio de Janeiro’s subúrbios Pentecostalism, margins and smells are put to work to construct new kinds of affective space.

On social media

Our graduates find a wide range of career paths open to them and are based all over the world. This week’s social media highlight is an insightful infographic, tweeted from @LSHTM, displaying the geographic destinations of LSHTM graduates.

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On-demand access to eBooks

The Library is currently providing access to thousands of eBooks from ProQuest, using a ‘demand driven acquisition’ (DDA) model. Subjects covered include health, economics, nursing, pharmacy, biology, botany, zoology, social sciences, and many more.  Readers can run a search as usual in Discover, and if you click on one of these titles and make a purchase request, the Library will consider acquiring the eBook. This gives you the chance to select eBooks that you need, and help shape the future of the Library’s eBook collection.

The extra titles can all be searched for in Discover, and will come up in results if relevant ones are available. By clicking on any of these titles you will be forwarded to ProQuest’s Ebook Central platform. Here you can access a five-minute preview of each eBook, giving you time to browse contents pages, sample the text, and decide if it is what you need (in the preview stage, you won’t be able to print or copy). Alternatively, if you already know that you want full access to the eBook, you can skip the preview and request the title directly. Getting a response will usually take up to three working days. You will receive an email letting you know whether or not you have access to the title.

Once the eBook is acquired by the Library, you’ll have full access to the text, and to the tools offered by Ebook Central.

Any queries, please email