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Universal Access to Preferred Primary PCI for STEMI in Malaysia: It is time to

Roll-‐out a sustainable Primary PCI Program

Conference Paper · June 2015

DOI: 10.13140/RG.2.1.3715.4728

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 Universal
 Access
 to
 Preferred
 Primary
 PCI
 for
 STEMI
 in
 Malaysia:
It
 is
 time
 to
 Roll-­‐out
 a
 sustainable
 Primary
 PCI
 Program
Dr
 David
 KL
 Quek,
 FRCP,
 FNHAM,
 FACC,
 FESC
NHAM
 Pulse,
 June
 2015
“I’ve got to defend my children, and yours, and do what’s right
to save lives… Obesity (STEMI) kills. There’s no question it
kills… People are dying every day. This is not a joke. This is
about real lives.” ~ Mayor Michael Bloomberg.1
Our Disparate Access to Healthcare
Malaysia is a middle-income economy in South-East Asia,
aspiring to become a fully developed nation by 2020. It has a
population of 30 million, of which some 70% live in urban
locations. Yet despite this aspiration to become fully
developed, both economically and also in terms of human
development, Malaysia has faltered in more ways than one. We
certainly can do much better.
It is true that our primary health care system is among the best
in the world, one that is praised by W.H.O. and emulated by
other less developed nations of the third world.2 But on the side
of tertiary healthcare, we appear to have stalled. On the one
hand, we have all the state-of-the-art amenities and expertise
for almost every serious ailment including non-communicable
diseases such as coronary artery disease and cancers; yet we
are grappling losing battles with rising cardiovascular diseases,
hypertension, diabetes, obesity as well as communicable
diseases such as dengue, influenza and multi-drug resistant
tuberculosis.3,4
But for many, diagnostic and therapeutic services are still
rather sporadic, inconsistent and not uniformly accessible.
There are wide differences in service availability or
accessibility among urban, suburban and rural-riverine
communities, as well as intra-city disparities.5 Most of the
urban areas are clearly very well equipped, but this does not
necessarily translate down into universal access and uniform
medical care for everyone. Sadly there is a wide chasm of
health outcomes being highest (worst) among the lowest
income group when compared with the highest income group.
(See Table 1)6 A gap of nearly 14 to 19 years (male vs.
female) for life expectancy at birth between the lowest to the
highest income group is unacceptable, and inequitable for a
‘developed’ nation status!
The sad aspect of our health system is that we are still stuck in
the past, with no declared universal access to healthcare for all
our citizens and residents.7 Even if we accept that no one is
ever turned away from treatment at most public hospitals and
health facilities, there is currently no mechanism to ensure that
everyone could access the appropriate medical care without
any worries about reimbursement or ability to pay.8 Some
patients have to join long waiting queues and some acute
emergencies are offered sub-optimum therapies for want of
better expertise or amenity.
Clearly we must consider embarking on a national program for
greater health equity. But this should be achieved without
economically burdening the public any more than it has thus
far.9 Undoubtedly, legislative policy and regulatory
frameworks need to be consistently and properly planned to
ensure better resource management of public funds, as well as
to rationalize private spending patterns.10 Note too that while
most nations enforce some sort of prepayment options and risk
pooling reimbursement mechanisms,11 any new plan that
demands or mandates more personal taxes or social/health
insurance premium contribution would be adversely received,
if not downright rejected! A realignment and/or an increased
reallocation of already budgeted public funds would be the way
forward. It is sobering to look at the newly imposed GST that
has been roundly condemned as a regressive tax that is
burdening the poorer segment more than the rich!12
Unfortunately in Malaysia, most of the treatment pathways for
major illnesses have been defined by one’s ability to pay, i.e.
those with means, health insurance or with third party payer
options for reimbursement are those who can afford to seek
quicker and timelier access to medical care at private health
facilities. Unfortunately this accounts for just around 14% of
the population as shown by our national health accounts data.13
As many as 37% or so pay out of pocket. On the other hand,
Malaysians with more limited funds have little choice but to
seek treatment at the hugely-subsidized or low-cost point-of-
service public
amenities, which are
already bursting at the
seams of demand
overload.14 For the
acute treatment of
some conditions,
speedy and universal
access to any
healthcare facility is a
must, if we are to
achieve a fair
modicum of best
practices in health care
as expected of a
modern state.
Our less than stellar management of STEMI
The lacklustre treatment of heart attacks or ST-elevation
Myocardial Infarction (STEMI) comes to mind when we
examine our NCVD data.15 Here, we have not progressed as
much as we would like to have. The majority of our acute
coronary syndromes especially STEMI are still treated with
medical only therapy or the less-than optimum fibrinolysis in
70% of the cases, with less than 10% being offered primary
angioplasty (Primary Percutaneous Coronary Intervention or
PPCI). Another 20% or so receive no targeted treatment due to
missed diagnosis or delay in first medical contact (FMC).
Malaysia’s Health Service under pressure…
Malaysia spends a total of USD 12 billion per year (latest
MYR 42.3 billion, 2012)13 on healthcare expenditure, through a
mixed reimbursement health system. The public-funded health
system caters to the bulk of the population. About 55% of the
total health budget comes from the public purse through tax
revenue allocations, and are used to defray 70% of total
hospital admissions, as well as 30% of the total number of
primary care outpatient services. The other 45% of the
country’s total health expenditure is provided by the private
sector on a fee-for-service mechanism, the bulk of which are
through third-party-payer mechanisms including health
insurers and employer-provided/subsidized Managed Care
Organizations (MCOs).10
Thus, wide disparity in timely access to the most advanced
forms of medical care is the norm in Malaysia. While basic
health services are readily and universally accessible, tertiary
and more advanced care is still sporadic and inconsistent,
depending to a large extent on locale, proximity, availability of
amenities/expertise and costs (who’s paying). By and large the
public sector provides a more limited and constrained basket of
services, based on tight finite budgets, and more queue-based
prioritization of needs and costs. Conversely the private sector
provides facilitated access to more advanced technology and
modern state-of-the-art medical therapies on the basis of
capacity of reimbursement, either via third party payers
(including self- or employer-provided health insurance
schemes) or out-of-pocket means.
Cardiology Services: public, academic vs. private
Let’s consider a more focused area, i.e. Kuala Lumpur our
captial city. Greater Kuala Lumpur (‘the Klang Valley’) has 21
cardiology centers with catheterization laboratories that can
offer expertise and access for primary angioplasty for heart
attacks. However of these 21 centers, only 5 are public sector
health facilities that are heavily subsidized for reimbursements
of all health care costs. The other 16 centers are private
hospitals that provide tertiary medical care on a fee-for-service
model. However, only 12 of these 16 private medical centers
provide routine tertiary cardiology care and primary
angioplasty services. 16 About half of the 200+ accredited
specialist cardiologists in the country are located in the Klang
Valley, who are credentialed to perform angioplasty.
But when it comes to seeking urgent treatment for STEMI, the
luck of the draw determines who and where you are presented
to, especially for those without any prepayment plans of
reimbursement. The bulk of newly incident STEMI patients are
referred to public centers where the overloaded system cannot
guarantee the best approach possible, so it’s either just medical
therapy or fibrinolysis based on timing and availability.
It is sobering to note that Myocardial Infarction is still the
primary cause of death (30% of all deaths) in Malaysia for the
past 35 years, over and above communicable infections and
cancers. Heart attacks or ST-Elevation Myocardial Infarctions
(STEMI) are increasingly common and represent a serious
cause of death in Malaysia, particularly in the major urban
areas. Cardiovascular Diseases (CVD) accounted for 244,472
admissions or 7.44% of total admissions to Malaysia’s public
and private hospitals in 2012. In 2012, CVD accounted for
some 25.1% of all deaths among hospital admissions in the
country.17
So how can we achieve or perform better for STEMI
management? STEMI is best treated with early and timely
primary angioplasty to re-open clogged-up heart arteries, to
help save and preserve heart muscle and function. PPCI has
been shown to save more lives. Unfortunately because of
multiple factors: some from misdirection as to costs, but mostly
because of logistics mismatch, many of Malaysia’s heart attack
patients still do not receive the best possible care i.e. timely
primary angioplasty.
So, as many as 70% of heart attack patients are only able to
access and receive fibrinolytic therapy (‘clot-busting’ therapy);
currently considered a second best option. Some 20% receive
no proper targeted treatment because of delay or access
issues.15 Only 10% have access to primary angioplasty, which
is now globally regarded as the treatment of choice. Primary
angioplasties for heart attacks are projected to nearly halve the
risk of death during hospitalization (4% vs. 7%), and over the
first year (7% vs. 12%) when compared to other treatment,
especially when these are carried out at accredited centres.18,19
At the current time in Malaysia, there is no national program to
address the issue of primary angioplasty as first choice for
treatment of heart attacks (STEMI). The government-funded
public sector has always maintained a hands-off approach to
coordinating or sharing of services with the private sector,
presumably because priorities elsewhere demand their greater
attention! Yet, there have been many areas and precedents
where public-private sharing and cross-referrals have taken
place, i.e. the shorthanded oncology and neurosurgical
disciplines that regularly employ private specialists.
Recently Institut Jantung Negara (IJN) our National Heart
Institute, has embarked on a collaborative strategy to involve
the Kuala Lumpur Hospital to strategize more timely referrals
of STEMI to its nearby facility. Furthermore, cardiology
services officials from the Ministry of Health for the Selangor
and Kuala Lumpur area have agreed on a more streamlined
approach to refer STEMI patients to some public and academic
cardiac centers for PPCI where appropriate.
Alas, private establishments have been omitted because of
concerns about reimbursement uncertainties. Sadly therefore,
this leaves out a chunk of the available private facilities and
expertise that can perform PPCI in a more efficient manner.
However, not long after these strategies have been mooted, the
Health Ministry started issuing cost-cutting directives about not
referring patients across public-academic platforms, because
this would increase costs for the federal government. The
reasons given were economic: budget cuts, belt-tightening to
mitigate our looming recession and address our runaway
budget deficit concerns!20
Therefore, for heart attacks occurring among the public, there
is an implicit practice, based on some intra-governmental
directive, for patients to be referred directly and only to the
public medical centres. Such a practice or directive is however
shortsighted and inefficient, because it is fraught with logistic
anomalies: more often than not, transfer and access is either
delayed, or in many cases, not available at all. This mismatch
of need vs. demand is due predominantly to limitations or
constraints of bed- or CCU-availability, lack of available
expert personnel, accustomed non-cardiologist physician-
decision bias, or perceived higher costs at private centers.
Therefore, for the capital city of Kuala Lumpur despite its
higher GDP, there are not enough concerted efforts to organize
a coordinated response to address this issue of delay in access
to this lifesaving procedure.
Suboptimal Choice of Fibrinolytic Therapy: Of course, there
is still a place for fibrinolytic therapy based on our curent CPG
guidelines for STEMI. But this should not be the default first
choice.21 Used as default first line therapy, many patients who
could have been better treated with primary angioplasty, would
be denied this preferred mode of therapy. While also beneficial
when compared to no treatment at all, fibrinolytic therapy has
been shown to be inferior to primary angioplasty in short and
long term results, in residual morbidity outcomes and even
deaths.22 Survival data suggest that primary angioplasty
reduces by half the one-year mortality rate that which is
achievable with fibrinolytic therapy, and that return to work
and life functionality, quality of life is also superior. Cost-
effectiveness measures also favor primary angioplasty in terms
of longer-term costs of therapy and economic loss analysis.23
According to our NCVD database, as many as 7-10 percent of
heart attack patients in Malaysia still perish within the first 7
days of hospitalization (the rate for best global standards is
now around 5%); with the 30-day mortality rate ranging from
11-14 percent. The first year mortality rate averages 15-18
percent.15 These do not reflect the best practices achievable
elsewhere, unfortunately.
Perhaps it is time to enact a pradgim shift in our dichotomous
approach to treating STEMI for Malaysians. Could we not
establish and coordinate a program to help educate, facilitate
access, transfer as well as to integrate the various facilities to
ensure that as many people as possible with heart attacks can
achieve this goal of timely access and therapy at the lowest
costs and best utilization of current resources, as best as
possible? It is certainly doable if some common vision and
mission can be established to realize this win-win strategy for
all, especially for all our patients.
A Greater Kuala Lumpur Area/Klang Valley STEMI PPCI
Project?
We could pilot this project to include all of Greater Kuala
Lumpur area or the Klang Valley, which has the metropolitan
population of about 6.9 million, as of 2010.
Costs of therapy: Since costs has always been a bugbear in
health access, we need to resolve this issue once and for all.
Treating a heart attack in the Klang Valley by primary
angioplasty costs approximately MYR 30,000 for a daytime
procedure with a single stent, standard medications, and a
routine uncomplicated hospital stay of 3-4 days.24 Care
requiring coronary artery bypass surgery (CABG) or during
off-office hours emergency setting can cost up to twice or three
times as much, with an additional cost of MYR 8-10,000 per
additional stent used. Medical treatment of heart attacks using
fibrinolytic therapy costs an average of MYR 12,000 for the
acute hospital stay of 3-4 days, if the cheaper streptokinase is
used, MYR 16,000 for tenectaplase. However, because of
expected increased rates of recurrent events and complications
utilizing the fibrinolytic method, the overall total economic
costs are estimated to be 4 to 5 times the total cost of primary
angioplasty in the longer term, per incident STEMI.
Based on the (estimated) expected 1,750 heart attack patients
per year, the cost for optimal care via primary angioplasty for
in-hospital costs alone in the Greater KL area would be MYR
60 million.25 If we include logistics, transfers and other
complication costs, this could add conservatively another MYR
10 million. We estimate that the full one year integrated
program would cost around MYR 70 million for the Klang
Valley alone.
Logistics/Costs Access issues: So how do we address the
issues of cost and logistics, to facilitate that as many heart
attack patients can gain timely access to preferred PPCI?
First we must change people’s mindsets! More often than not,
public and payer preconceptions are that private healthcare are
associated with unaffordable higher costs. Thus, most heart
attack patients are either self-referred or are preferentially
channeled to ‘cheaper’ public hospitals and facilities by
default. This is also true when ambulance services are called
upon for emergency transfer. These default transfers have been
known to cause great strains on the limited resources of these
heavily subsidized public centers, and result in bottlenecks of
delayed or suboptimal care. Thus, we also need to address this
issue of engaging emergency and ambulance services as well
as primary care practitioners to enlighten them that we now
have a more concerted and integrated approach to optimum
STEMI therapy, regardless of costs.
So what can be done about the costing issue?
The Rationale of Bridging the Private-Public Gap
Is this current public-private dichotomy of care, and lack of
coordinated access viable or sustainable? Or can this be
mitigated? In West Jakarta, Indonesia, there is now an ongoing
coordinated project (both public and private facilities) that
integrates all PCI-capable centers to engage in the best
optiumum treatment for STEMI.26
One suggestion for us here in Malaysia, is to set up a not-for
profit but self-funding private-public financed corporation/
consortium to develop a working cost-effective model and
integrated proposition to the health authorities. But we also
need buy-ins from healthcare payers (insurers, third party
payers, employer-health schemes, public sector health cost
allocation) on how to develop and execute a comprehensive
seamless system to ensure the best care for heart attack patients
i.e. coordinated transfer of patients, providing well-trained
personnel, consistent and routine access to coordinated
pathways, i.e. organizing cathlabs (cardiac catheterization
laboratories) to operate 24/7 for acute PCI, seamless structural
admission/registration mechanisms and integrated approaches
including reimbursement models for timely primary
angioplasty. The goal is for this improved system to be rolled
out for action within a year or as soon as possible.
Social Impact Bonds: Possible Financing Model
Recently there have been some touted new models of joint
Public-Private Financing Initiatives, not just based on for-profit
ventures, but also for social causes. This came about when
Corporate Social Responsibility (CSR) and grant giving are
seen as one-off contributions that often do not see committed
or measurable outcomes. So how about creating possible
higher-risk “Pay for Success” joint venture models to help
bring about more accountability and measureable results?27
This began as an experimental model at Peterborough UK to
help reduce the rate of ex-inmate recidivism in 2010, (via a £5
million fund from individual investors and Charities) and since
then has spread globally quite successfully.28 UK now has 14
Social Impact Bond (SIB) Programs. The rationale is to have a
win-win approach at achieving targeted goals and measureable
outcomes, through unlocking private investments for social
outcomes (where governments would not have otherwise
funded, or whose priorities are elsewhere), using private risk
investment ventures and government guarantees for above
average returns on investment for success.29
Although SIB programs have been used more for social
engineering initiatives, there are now SIBs for achieving better
health outcomes too. The Fresno’s SIB Program30 for reducing
asthma in the community started in 2013 and is now another
success story that is leading to more such programs in the
USA. In fact a Social Impact Bond Act is being proposed in the
USA, starting with a USD 300 million grant.31
Using this SIB model it is possible to seriously consider
making this PPCI for STEMI work for all, at least until the
government feels the need and the urgency to totally finance
the costs of this best-practices program. As can be seen in the
model below, costs can actually be saved from the public
purse.27
Source: Social Finance US
Target Goals
• Ultimately the aim is to offer a sustainable timely,
coordinated, seamless and universal (‘all-comers’) access
for the best current treatment of heart attacks that would
benefit the 7 million population of the Greater Kuala
Lumpur/Klang Valley.
• To achieve this, a reorganized (mixed) payment or
reimbursement model to help realize this goal will be
made acceptable to the payers and stakeholdders for this
healthcare initiative, i.e. this would include health
insurance companies, other third party payers (TPP), and
the Ministry of Health Malaysia.
• We must establish a cost-efficient structure for the more
systematic allocation of resources for both manpower and
facilities, as well as a re-definition of its policy goals with
reference to this targeted niche area of healthcare.
• We can launch a Social Impact Bond initiative with
measurable targets to draw in investors both from
individuals as well as from charities and other corporate
players with CSR programs.
• This will serve as a pilot template to roll-out nation-wide
to improve the consistent delivery of better evidence-based
healthcare of heart attacks for Malaysians.
Value proposition for all:
• This will enhance and raise the profile of the Health
Ministry as a policymaking and service provider
• More if not all healthcare providers including cardiologists
would be engaged in this national exercise and duty of
universal access to best care for STEMI
• Ultimately the benefits of early and best treatment of heart
attacks for the patients would be manifest, as this will
translate into better longer-term outcomes, a healthier
more productive population, as well as incurring lower
total economic costs.
Proposals on Capital Needs and Other Resources
• Set up a holding corporation that will be the overall
coordinating body to plan, obtain funding and liaise with
all the participating stakeholders, which will include the
Ministry of Health Malaysia, to include its public tertiary
hospitals with primary angioplasty amenities, academic
medical centers and all private medical centers with
similar capabilities within the greater Kuala Lumpur area
(Klang Valley).
• Obtain a start-up fund with initial operating costs target of
MYR 10 million, to kick start the program, (from a
seeding fund from the Ministry of Health from its annual
budget?) We should be able to achieve MYR 70 million
from other targeted sources for the initial first year with
coordinated, integrated and careful budgeting and
planning.
• From our Malaysian hospital utilization data,32 it is
suggested that some 70% of patients choose the public
sector hospitals because of cost considerations. This means
that the public purse would be brought to bear to
reimburse this program if this is shown to be true. But
because there are only 5 public/academic hospitals capable
of providing primary PCI, this will severely overload the
services of these hospitals. From our estimate of 1,750
heart attacks in the Klang Valley per year, some 1,225 or
some 3 to 4 patients would be presenting to these public
centers every day! Therefore, this would be quite taxing on
these already short-handed resources!
• Disburse and distribute these heart attacks patients to the
nearest available facility! This way we can spread these
patients more widely and evenly so that every provider
facility be they academic or private or public center, can
cope and provide the necessary services of primary PCI in
as timely and expedient a manner as possible! That is why
we need to take out the equation of reimbursement
consideration, and institute a mechanism to ensure that this
is possible. When evenly distributed, the 17 centers would
each see an average of 105 patients a year, or one patient
in every 3 days. This then, should not be a burden to
existing cardiac catheterization laboratory practices.
• Source funding or re-insurance from third party payers
such as health insurers, managed care organizations,
employer based health benefit managers.
• Engage in a win-win dialogue with all private hospital
CEOs and practicing cardiologists to buy into this
program, with discussion on how to implement a case-mix
funding mechanism on primary PCI for heart attacks, and
to come up with a per patient quantum of cost that is
acceptable. DRGs and global budgets per ailment comes to
mind.
• Tap into how to utilize ‘Social and Welfare contribution”
(corporate social responsibility, CSR) funds (quantum to
be derived from Private Healthcare facilities by law)33 to
cater to other less endowed patients who do not have any
insurance or who may not be able to pay out of pocket, i.e.
so as to make this program all inclusive to benefit the
poorer patients among the public, in as wide an area as
possible. We must ensure that no one patient with a heart
attack is turned away for lack of funding or reimbursement
plans.
• Ensure transparency and clarity of purpose of being a non- • Lack of funding or commitment for agreed reimbursement
profit program, i.e. strive to keep the administrative costs plans most likely to involve DRGs or case-mix quanta of
of such a coordinated program to below 5-10% of the total disbursement.
costs. • Lack of support from the public sector to allow
• Engage all ambulance and emergency operators to engagement with the private sector especially with regards
coordinate how to transfer and deliver patients with heart to distributing and sharing patients or fund disbursement.
attacks to as expedient and quickly a manner as possible to • Lack of ministerial support to institute a mandatory
the nearest available resource facility. program of social welfare contribution or CSR funding
• Roll out a media blitz campaign to the public and also to from private healthcare facilities.
primary care physicians and clinics on how to implement • By utilizing the Social Impact Bond model of financing it
this program, with direct and timely referral to all is possible to mitigate against losses, but careful attention
participating facilities for primary angioplasty. to performance indicators, measureable indexes and costs
• Design and manage a comprehensive information and controls to prevent overruns are critical.
technology system to document and coordinate this • The actual number of heart attacks may be more than
program. We understand that there are some medical estimated, this could increase the overall costs for the
device companies with such programs that could be program a few fold, but the plan remains achievable based
purchased or sponsored with win-win initiatives and on a per pax reimbursement protocol with government
collaboration, e.g. Medtronics Inc. Hence the need to build guarantees and public purse disbursement and allocation.
smart partnerships with these companies on a shared • Ultimately the overall cost of health care cost caused by
benefit platform.34 heart attacks would be lower with better quality of life and
• Work with certain pharmaceutical companies to ensure survival without or with lower major adverse
that all patients receive the necessary anti-clotting (dual cardiovascular complications (MACCs).
antiplatelet therapy, DAPT) medications for a stipulated
minimum period 6 months to one year) for the best Conclusion
effects/outcomes to be realized following primary
angioplasty. Some of the newer antiplatelet agents are It is time for our cardiac fraternity to take the lead in
expensive and these can be negotiated with their establishing the best care strategy for our heart attack (STEMI)
manufacturers to agree on a minimum base price to benefit patients. We can make our heart care world class and at par
all patients.35 with the best outcomes, not just for a few privileged able-to-
• Involve and enlist our entire cardiology fraternity of pay patients, but for all. Let’s help realize this one niche aspect
Malaysia to support this program i.e. our National Heart of offering universal access for all, for the best (optimum)
Association of Malaysia (NHAM). Ensure that every one management of STEMI, and set an example of possible
of our cardiology fellows and members participate in healthcare excellence in this country, as we march toward
making this program a success. 2020!
• Take lead to organize and ensure adequate and continuous
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services for primary PCI on a 24 hours a day, 7 days a
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1
week (24/7) ready structure, for all participating hospitals
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responsible and ready to offer this service and maintain http://www.nytimes.com/2013/03/12/nyregion/judge-­‐invalidates-­‐
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13 32

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Registry,
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 NHAM,
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 Kuala
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2011.
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20

 Jennifer
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21

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th
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22

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1814.
 
23

 Fazel
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Myocardial
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 Investigators.
 Choice
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strategy
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 hospitals
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intervention:
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24

 Hospital
 cost
 estimates
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 a
 Klang
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 private
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PPCI
 STEMi
 MYR
 30,000;
 CABG
 (uncomplicated)
 MYR
 60,000.
 
25

 Number
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 STEMi
 estimated
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 NCVD
 database
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 250
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100,000
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 oer
 year.
 For
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 nearly
 7
 million
 in
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 Klang
 
Valley,
 this
 would
 be
 1,750.
 
26

 iSTEMI:
 Indonesian
 STEMI
 Network
 for
 West
 Jakarta
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collaboration
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www.isic.or.id/pages/istemi
 
27

 Jon
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Sept
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 http://onforb.es/10QyT4r.
 
28

 Emma
 Disley,
 Jennifer
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 RAND
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 Phase
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the
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 results
 Social
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Peterborough.
 Ministry
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 2014
 
29

 Toby
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 creator-­‐founder
 of
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 Finance
 and
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 model.
 
http://www.socialfinance.org.uk/about-­‐us/board-­‐and-­‐team/
 
30

 The
 California
 Endowment
 Awards
 Grant
 to
 Social
 Finance
 and
 
Collective
 Health.
 Social
 Finance
 press
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 25,
 2015,
 on
 
the
 Nonprofit
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 Fund
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http://payforsuccess,org/sites/default/files/fresno_asthma_demonst
ration_project_press_release.pdf,
 accessed
 May
 2015.
 
31

 Social
 Impact
 Bond
 Act.
 
http://toddyoung.house.gov/uploads/Social%20Impact%20Bond%20
Act.pdf
 

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