Social impact bonds to address social determinants of health

“This is not a blog post.” —René Magritte

Of course that’s a joke. My point is that I have been intending to write a piece about this subject for long enough to know that I’m unlikely to every actually write it. Below are the bits I’ve pulled together. This, more-or-less, has been sitting in my post draft workspace for over two months. If you want to take the following (or even a part of it) and write something, good for you! Let me know when you do! Otherwise, I may someday come back to this, but I wouldn’t bet on it.


  • There’s more to health than health care. Estimates vary, but social determinants and environmental factors play a substantial role. [One side interest/task is to go through the linked document and see if there’s really anything new in it or that which it cites that Adrianna and I did not cover in our prior digging into social determinants. See this FAQ.]
  • Relative to other countries with better health outcomes, we spend a much higher proportion on health care than on other social services. This might explain why our health outcomes are so much worse (Taylor, Bradley). Our spending is not allocatively efficient.
  • If this is indeed the key, the straightforward thing to do would be to reallocate spending from health care to other social services.
  • This may be politically hard. [Why? Need to get to the notion that people are skeptical of the benefits of social services spending or otherwise unwilling to fund, if true.]
  • Another approach, perhaps more politically viable, are social impact bonds. Examples in a 2014 Health Affairs paper.
  • Can they scale up? Should they? Consider the effort and planning. Consider the capital requirements, the motivations of investors. Consider the challenges of finding good implementers. Consider the distortions and benefits of needing short- to medium-term, quantifiable outcomes (5-7 year horizon?).  Consider the difficulties of finding good comparators, of study design.
  • What happens after a successful project? What should happen?



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