Return on Investment for Emergency Obstetric Care Training

chase away on Investment for pinch obstetrical administer Training complaisant Return on Investment for Emergency obstetrical C be Training in KenyaDedicationTo philanthropy and every those contributing to do the world a better placeList of tables plug-in 11 Summary table of complaisant impact assessment methods fudge 21 WHO emergency obstetric c ar signal functions.. elude 31 Krlev et al. 12-point quality assessment framework disconcert 32 Sources of call backd SROI studies.Table 33 Criterion quality scores of health SROI studies crosswise the 5 dimensionsTable 34 health treatments that deplete been measured with SROITable 35 Summary table describing applications programme of the SROI methodological analysis in HealthTable 36 Summary of duration of health SROI outline.Table 41 Outputs of the current phase of the Making it Happen programmeTable 42 Content of the LSS-EOC NC.Table 43 dissemination of Kenyan population across age groups.Table 44 Kenyan Key development indi cators..Table 45 EmONC indicators in Kenya compared to UN standards.Table 51 Description of SROI principles.Table 52 MiH outcome and output data indicators relevant for SROI analysisTable 61 Stakeholder analysis of the EmONC training component of the Making it Happen programmeTable 62 Primary and secondary data conveyd from the included stakeholdersList of figures epithet 11 Types of Social Return on Investment StudiesFigure 21 Annotation of the logic model (version 1).Figure 22 Annotation of the logic model (version 2).Figure 23 DFID 3Es + CE framework for Value for Money..Figure 31 Schematic representation of the abstract framework underpinning the reviewFigure 32 PRISMA flow diagram summarising the search process.Figure 33 Mean quality scores of health SROI studies since 2005.Figure 34 Number of public health SROI articles published since 2005.Figure 35 Number of health SROI studies published by year, video display countries where the methodology was appliedFigure 36 Distribut ion of countries conducting SROI studiesFigure 41 Map of Kenya showing the eight provinces and the surrounding countriesFigure 51 SROI process mapFigure 52 Methods to be apply within the SROI data collection stages..Figure 61 outline of stakeholders related to EmONC training in KenyaList of appendicesAppendix 1 Search strategyAppendix 2 Systematic review resultsAppendix 3 moral philosophyAppendix 4 Materials relating to Making it HappenAppendix 5 QuestionnairesAbbreviationsACAFIAtkisson Compass Assessment for Investors supportAcquired Immune Deficiency SyndromeBACOBest Available Charitable OptionBEmOCBasic Emergency Obstetric CareBEmONCBasic Emergency Obstetric and Newborn CareBoP Base of PyramidBScBalanced ScorecardBVABlended Value AccountingCAQDASCEmOCComprehensive Emergency Obstetric CareCEmONCComprehensive Emergency Obstetric and Newborn CareCBACost Benefit psychoanalysisCEACost-Effectiveness AnalysisCMA Cost-Minimization AnalysisCMNHCentre for Maternal Newborn HealthCRTClus ter Randomised TrialsCSOCivil Society OrganisationCUACost-Utility AnalysisDALYs Disability-Adjusted feel YearsDFIDDepartment for International increaseDHDepartment of HealthDHS Demographic and Health mountainEE scotch EvaluationEmOC Emergency Obstetric CareEmONCEmergency Obstetric and Newborn CareEOC NCEssential Obstetric Care and Newborn CareFGFocus GroupFGDFocus Group DiscussionGRIGlobal insurance coverage InitiativeHCPHealth Care ProvidersHEFCEHigher Education Funding Council for EnglandICPIntegrated Care and PreventionIDIIn-Depth InterviewKHSSIP Kenya Health Sector Strategic and Investment PlanKIIKey Informant InterviewKPIKey Person InterviewLADSILabour and Delivery Satisfaction IndexLATHLiverpool Associates in Tropical HealthLEMLocal Economic MultiplierLMICsLow and Middle Income CountriesLSS-EOCNCLife Saving Skills Essential Obstetric Care and Newborn CareLSTMLiverpool School of Tropical MedicineMARPMost At Risk PopulationMDG-S quite a littleMillennium Development Goal S terminateMICSMultiple Indicator Cluster SurveyMIFMeasuring Impact FrameworkMiHMaking It HappenMMRMaternal Mortality RatioMNHMaternal and Newborn HealthMOHMinistry of HealthMOMSMinistry of Medical serviceMOPHSMinistry of Public Health and SanitationMSCMost Significant ChangenefNew Economics FoundationNGOsNon-Governmental OrganisationsOASISOn-going assessment of Social ImpactsOVCOrphan and Vulnerable ChildrenPLHIVPeople Living with Human Immuno-deficiency VirusPLHWAPeople Living With AIDSPSIAPoverty and Social Impact AnalysisPTOPerson Trade-OffQALYsQuality-Adjusted Life YearsQIQuality ImprovementRCOGRoyal College of Obstetricians and GynaecologistsRCTRandomised Controlled TrialsREDFRoberts endeavor Development FundRFRoberts FoundationROIReturn on InvestmentSAASocial Accounting and AuditingSBASkilled consume AttendantSCStakeholder ConsultationSCBASocial Costs-Benefits AnalysisSDRSocial Discount RateSIASocial Impact AssessmentSIAASocial Impact Analysts AssociationSRASocial Return Asse ssmentSRHSexual and Reproductive HealthSROISocial Return on InvestmentSSQSix Simple QuestionsSTDsSexually Transmitted InfectionsSVAStakeholder Value AddedTBLTriple Bottom LineToCTheory of ChangeTSOThird Sector OrganisationUKUnited KingdomUNUnited NationsUNICEFUnited Nations Children FundVfMValue for MoneyWBWorld BankWHOWorld Health nerve1 Introduction1.1 Purpose of the chapterThis chapter introduces the fond return on investment methodology its definition, history as well as peculiaritys and weaknesses of its application. It then proceeds to range examples of previous applications of the method, explores any previous intersection of the methodology with the maternal and newborn health field and provides the rationale for the study. Finally, the objectives of this interrogation and an overview of the thesis are provided.1.2 What is Social Return on Investment?The first definition of Social Return on Investment (SROI) is a simple financial assessment of socio- sparing apprise. SROI compares a projects net benefits to the investment required to generate those benefits over a certain period of time (Emerson and Cabaj, 2000).Over time, this definition has been modified. In the most recent SROI methodology guidance, SROI is defined as a framework for measuring and accounting for the much broader concept of note value. It seeks to reduce inequality and environmental degradation and improve well being by incorporating cordial, environmental and economic costs and benefits (Nicholls et al., 2012). This definition is most commonly referred to in the literature, when authors define SROI, probably because it is stated within the SROI guidance.New Economics Foundation (nef) as well defines SROI as an analytic tool for measuring and accounting for a much broader concept of value, taking into account social, economic and environmental factors (nef, 2014).SROI measures change from the aspect of stakeholders that sustain or contribute to a particular activity, inte rvention, project, programme or policy. It tells the story of how change is being created by measuring social, environmental and economic outcomes and uses monetary value to represent them (Nicholls et al., 2012). Data collection and subsequent analyses allow calculation of a benefits-to-costs ratio. For example, a ratio of 41 indicates that an investment of 1 delivers 4 of social value.There are two types of SROI (Nicholls et al., 2012) Figure 1-1Evaluative SROI This retrospectively measures outcomes that have already happened.Forecast SROI This estimates how much social impact will be generated if the activities to be conducted find their intended outcomes.Figure 1.1 Types of Social Return on Investment Studies1.3 History of SROIA review of the development of the SROI methodology would aid understanding of the initial considerations of those who genuine the tool and the capabilities and potentials of the tool. This understanding is critical for this research as it provides a fou ndation upon which the application of the SROI framework in the maternal and newborn health (MNH) area can be better understood.Roberts Foundation (RF) developed the initial SROI framework in 1996, presented in a report titled New Social Entrepreneurs The Success, Challenge and Lessons of Non-profit Enterprise Creation (REDF, 1996). The purpose of the first SROI report by REDF was to demonstrate the blend of financial, social and environmental value that all the social enterprises within REDFs keep portfolio were producing compared to the total investment the organisation was making. This first SROI did not attempt to account for all benefits accrued from a programme, but estimated the cost savings or receipts contributions that are attributed to the programme. The framework utilised a modified discounted cash flow analysis for this calculation to demonstrate impact (Emerson and Cabaj, 2000 Emerson et al., 2000).In 1997, the RF, under its new scuttle Roberts Foundation Enterpris e Development Fund (REDF) updated the framework so to have the capacity to account for total organisational social return on investment and adjusted to be able to account for actual performance that could be continuously updated. REDF recognised more than limitations in the methodology (Emerson et al., 2000), but has since not produced any come along SROI reports or guidelines. However, the concepts that underpinned the development of this initial framework have been built upon in the subsequent development of the methodology over the past two decades (Tuan, 2008). Guidelines for SROI application have been produced in year 2000 (Emerson and Cabaj, 2000), 2004 (Lingane and Olsen, 2004) and 2006 (Scholten et al., 2006). In 2008, the United Kingdom (UK) positioning of the Third Sector (Now referred to as Office for Civil Society (Civil Society Media, 2010)), which is responsible for charities, social enterprises and voluntary organisations in the Cabinet Office (UK Government, 2014 ) launched the Measuring Social Value project (Arvidson et al., 2010) and this led to the development of an updated guideline in 2009 (Nicholls et al., 2009) and the production of an some other revise three years later (Nicholls et al., 2012).These revisions have over the years integrated the initial REDF SROI methodology, which was essentially a social impact measurement tool with principles and processes normally utilize in economic valuations and financial return on investment to build a framework that captures social, economic and environmental impacts of interventions (Rotheroe and Richards, 2007). This concept of capturing the broader impacts is widely referred to as the triple bottom line (Norman and MacDonald, 2004), which is in itself encapsulated within the blended value accounting theory (Emerson, 2003). Furthermore, through this evolution, a more particular propositioned stakeholder analysis is at present included, shorter time frames are used for estimations and a process to adjusts the results for outcomes that may be attributable to different organisations has been incorporated into the calculation of the SROI ratio (Tuan, 2008).Discussions on how best to complex body part the methodology are on-going and networks such as the European SROI Network (ESROIN), formed in 2004, the SROI Network (international), formed in 2008 and subsequently affiliated networks formed in Sweden, Canada and Australia, are constantly leading and shaping this process (SROIN, 2014a). The methodology is gradually gaining interest in Africa and Asia too. The drive to develop the methodology has come from within and without the third base empyrean, as third sector organisations (TSOs), such as not for profit organisations, charities and voluntary organisations, are increasingly getting involved in delivering public function and are viewed as development partners who need to show value for money (Netten et al., 2010). On one hand, TSOs are pushing to become better in being accountable and demonstrating the value of their activities to donors. On the other hand, the focus of funding organisations has shifted from output to outcome and impact and from generous giving to accountable giving, through which they can demonstrate that evidence-based decisions have informed their choice of funded interventions, projects or programmes (Leat, 2006).1.4 Application of the SROI methodologyThe application of the SROI framework can vary from measurement of the impact and social value generated by a project to a programme or indeed to an entire organisation (Millar and Hall, 2013).A rapid search of academic databases does not retrieve substantial amounts of research work that have used the SROI methodology, however the methodology is very popular within the third sector and has been widely embraced by the Office of the Civil Society, donors, commissioners and the public sector (Ainsworth, 2010 Heady, 2010). Its wider practice-based use but limited applicatio n within academia restricts its development and could potentially be the reason for its minimal expenditure (Arvidson et al., 2010 Ebrahim and Rangan, 2010).Since its first use by REDF in 1996 (Emerson and Cabaj, 2000), the SROI methodology has been broadly applied to many organisations and within many industries. Examples of its use across different sectors include agriculture, where it was used to account for impact of care farming (Leck, 2013) environmental, where it was used to account for impact of a natural regeneration project (Weston and Hong, 2012) vigor, where it was used to account for impact of energy efficiency of homes in Germany (Kuckshinrichs et al., 2010) social, where it was used to account for impact of providing training and employment for blind people (Sital-Singh, 2011), commit, where it was used to account for impact of a co-ordinated shared transport service which provides access to workplace, training and childcare in rural Scotland, where no alternative transport is available. (Wright et al., 2009) and indeed health, where amongst other examples, has been used to account for impact of a community-based paediatric asthma programme and provision of highly nutritious breakfast for school children in Sydney, Australia (Bhaumik et al., 2013 Varua and Stenberg, 2009).As regards its application in health depict in detail in Chapter 2 systematic review of SROI application in health, It is worth noting that in 2009, the UK Department of Health (DoH), with the support of the Cabinet Office, commissioned an action research project on which five health focused social enterprises were supported to conduct SROI analysis (Department of Health, 2010). This research demonstrated the relevance of the SROI methodology to the health sector and proved that there were additional benefits of using the methodology (Millar and Hall, 2013).However, to the best of our knowledge, though relevant and appropriate, there is no reported evidence of the applicati on of the SROI methodology in the field of maternal and newborn health.1.5 Difference between SROI and other related methodologiesAs mentioned above, the SROI methodology has evolved from a combination of social impact assessment tools and economic evaluation tools. It is therefore important to understand how SROI differs from these existing tools and identify what innovative approach it actually offers.When compared to other social impact measurement tools, there are subtle differences. There are several tools that have been previously or are currently being used in measuring and accounting for social impact (Acumen Fund, 2007 Brest and Harvey, 2008 Brest et al., 2009 Centre for High Impact Philanthropy, 2008 Clark et al., 2004 Emerson et al., 2000 Maas and Liket, 2011 Maas, 2008 Maughan, 2012 Nicholls et al., 2012 Owen and Swift, 2001 Schaltegger et al., 2004).Table 11 Summary table of social impact assessment methodsMethodPrimary application to Date Process subject Impact Moneti sationNon ProfitFor ProfitGovernmentAcumen ScorecardAtkinsson Compass Assessment for Investors (ACAFI)Balanced Scorecard (BSc)Benefit-Cost AnalysisBest Available Charitable Option (BACO)Base of Pyramid (BoP) Impact Assessment FrameworkCost per ImpactExpected ReturnGlobal Reporting InitiativeLocal Economic Multiplier (LEM)Measuring Impact Framework (MIF)Millennium Development Goal Scan (MDG-Scan)Most Significant Change on-going Assessment of Social Impact (OASIS)Poverty and Social Impact AnalysisSocial Accounting and Auditing (SAA)Social Costs-Benefits Analysis (SCBA)Social Return Assessment (SRA)Social Return on Investment (SROI)Stakeholder Value Added (SVA)Theories of ChangeTable 1-1 shows the reveal characteristics of these different social impact measurement tools described in the literature, identifying the tools that monitor efficiency and durability of outputs, indicators or variables (process) tools that relate outputs and outcomes and to substantiate incremental outcomes a bove what would have occurred if the intervention was not implemented (impact) and tools that monetize outcomes and/or impact by transforming them to monetary value (monetization). Finally the table details the sector(s) in which the method has thus far been applied non-profit (third sector), for profit (commercial) or public sector (government).Of these tools, SROI appears to have gained wide acclamation because of its involvement of all stakeholders, who independently define the value they have experienced because of the intervention. In addition, SROI monetises costs and benefits and also ticks all the boxes of the logical framework, as it accounts for processes, outcomes and impact (Arvidson et al., 2010 Nicholls et al., 2012).The other similar methodologies to SROI are Economic Evaluation (EE) tools. These compare two or more alternative interventions in terms of their costs and benefits (Drummond et al., 1997). Economists have distinguished quartette types of economic evalua tion Cost-minimization analysis (CMA), Cost-effectiveness analysis (CEA), Cost benefit analysis (CBA) and Cost-utility analysis (CUA). While the definition of cost remains the same, the manner of accounting for the benefits differs across the types (Drummond et al., 2005). These different types of EE are described belowCost-minimization analysis (CMA) In which, there is proven evidence that equivalent effectiveness of the comparators in question. Thus the more cost-effective option would be the cheaper one (since both options have similar outcome).Cost-effectiveness analysis (CEA) Effectiveness is measured in natural units such as smell years gained.Cost benefit analysis (CBA) Costs and benefits are monetised, with the cost-effective option being the one that results in a lower monetised ratio.Cost-utility analysis (CUA) Outcome is measured in Quality-adjusted life years (QALYs) or Disability-adjusted life years (DALYs), which is a composite metric of both length and quality of lif e.When compared to the SROI methodology, whereas a bad focus of economic evaluation tools is on the microeconomic evaluation of the impact of any intervention, SROI accounts for not just economic value, but social and environmental impacts. It has been described as an extension of the cost-benefit analysis that incorporates broader socio-economic outcomes (Westall, 2011). In addition, SROI focuses on stakeholders, uses financial proxies, is more of a management tool, is more likely conducted by organisations themselves, while CBAs are ordinarily conducted by external agents and the most up to date guidance does not recommend comparing estimated SROI ratios, unlike CBAs that are designed to be comparable. However, these differences appear to be deeply based on the style of each approach, rather than the true substance (Arvidson et al., 2010).1.6 Strengths and limitations of the SROI methodology1.6.1 Strengths of the SROI methodologyPractitioners and previous authors have identifie d some of the key strengths of the SROI methodology.Firstly, the fact that the SROI process generates a singular ratio that captures the broader impact (positive and negative) of an intervention is perceived as a key strength (Millar and Hall, 2013).One other strength is its meaningful engagement of stakeholders and its representation of their benefits in ways that are unique to the stakeholders themselves (Millar and Hall, 2013).More so, the fact that this benefits experience or impact experience is being explained from the perspective of the stakeholder is a unique characteristic of SROI, and this important stakeholder view is often neglected in conventional impact evaluation tools (Rauscher et al., 2012).In addition, the method provides a computer program for social enterprises to leverage and/or effectively communicate their impact. This ultimately promotes better communication amongst all partners, whether they are beneficiaries, funders or implementers (Mdee et al., 2008).The SROI process also strengthens accountability and transparentness systems of social enterprises (Arvidson et al., 2010).Finally, the SROI process is a very useful auditing tool to aid management decisions and service improvement (Social Ventures Australia (SVA) Consulting, 2012).1.6.2 Limitations of the SROI methodologyHowever, there are limitations of the methodology, just as there are of other impact evaluation methodologies (Arvidson et al., 2010).Some methodological limitations that have been raised include the difficulty of attaching financial values to soft outcomes that require subjective evaluation to generate financial proxies (Lingane and Olsen, 2004) such as self-esteem or confidence (Bertotti et al., 2011).Albeit still in developmental stage, is the Wiki Values, Outcomes and Indicators for Stakeholders (VOIS) database of the SROI Network is an attempt are to standardise such outcomes by recommending indicators and values of such outcomes that can be used to account for them (Rauscher et al., 2012). An example of a health related outcome on WikiVOIS is change in incidence of abortion. Contributors to the database have suggested that cost of medical termination of pregnancy can be used to value this outcome in Canada (The Global Value Exchange, 2013).In addition, the methodology needs an estimation of what would have happened anyway to calculate the value that can be attributed to the specific organisation, programme or intervention, however, this counterfactual data is seldom available (Cordery, 2013 Heady, 2010).Furthermore, the lack of comparability of SROI ratios across different organisations and/or interventions is perceived as a limitation (Ryan and Lyne, 2008).On pragmatic grounds, SROI methodology is adjudged to be cost-intensive and requires the expertise and know-how of professionals and in some cases training, some of which small organisations cannot afford (Wood and Leighton, 2010).1.7 Rationale for the studyThough applicable and relev ant, to the best of our knowledge, there is no documented application of the SROI methodology in the area of maternal and newborn health. For most MNH interventions, the key beneficiaries are the women and their families. There is currently no tool that captures the perspectives of all these stakeholders on impact of any intervention in one summary figure. This underscores the need to explore the use of primary data that will include inputs of those benefiting from MNH interventions, as this may potentially be useful in identifying the most complete estimate of the impact of these interventions. To buttress this, some authors have pointed out that this complete evaluation of MNH interventions needs to include identification of the most culturally appropriate intervention for each local setting and peculiar issues unique to the setting. Those who are the major beneficiaries of the intervention are better positioned to identify these culturally appropriate interventions. Thus the call for culturally sensitive impact evaluations, which attempt to identify specific causes of problems, rather than basing decisions on superficial indicators such as maternal mortality rate, which is only quantitative and does not capture softer outcomes that also demonstrate impact of an intervention (McPake and Koblinsky, 2009 Pradhan, 2008).Secondly, data used as maternal health indicators are usually generated from relatively credible sources such as the Demographics and Health Survey (DHS), Multiple Indicator Cluster Survey (MICS) and World Development Indicators, but the problem of lack of uniformity in the process by which the indicators were generated remains (Pradhan, 2008). This is complicated by the fact that a large number of developing countries, that receive aid, do not have accurate or complete secondary data to base impact evaluation on (WHO,