Social return on investment for emergency obstetric care training in Kenya

Background: Globally, there has been increasing interest to demonstrate value-for-money of interventions using various approaches including social return on investment, which is a form of social cost-benefit analysis. This study pioneered its application in maternal and newborn health. Specifically, the methodology was used to assess the social impact and value-for-money of an emergency obstetric care training intervention for health care providers in Kenya. Methods: Qualitative methods and literature review were used to identify key stakeholders who were direct beneficiaries of the training; and map, evidence and financially value its outcomes. These qualitative findings were triangulated with quantitative evidence from existing literature and programmatic data, which helped to establish impact. Quantitative methods were also used to account for the financial investment (input) used to implement the intervention and output produced. Both qualitative and quantitative findings were incorporated into the impact map, to estimate the social return on investment ratio. Sensitivity analyses were done to test assumptions and the pay-back period estimated. Stakeholders who were not deemed direct beneficiaries were engaged to establish strengths, weaknesses, opportunities and threats of the intervention. Results: Multiple numbers of key stakeholders of the training were engaged via 28 focus group discussions, 18 interviews, and three paired interviews. Trained health care providers, women who received care from them and their newborns are training primary beneficiaries. From the thematic analysis, key emerging themes were that training led to positive outcomes including improved knowledge, skills and attitude with patients. However, there were concomitant negative outcomes including increased workload because of new patient expectation and frustration from inability to practise what was learnt. Women had positive opinions concerning the quality of care that they received. They expected positive outcomes including avoiding maternal and newborn morbidity and mortality. However, women affirmed that negative outcomes could occur, attributable to health care providers, themselves or simply due to chance. These outcomes experienced by both health care providers and women who received care from them have been mostly reported in the literature and evidenced from programme data. However, ‘increased workload’ is reported as increased care provision in the literature and ‘increased frustration due to inability to practise what had been learnt following training’ had not been directly linked to training previously. Based on programmatic data, total implementation costs was £1,079,383 for the 2,965 HCPs that were trained across 93 courses. The cost per trained HCP per day was £72.80. The total social impact for one year was valued at £13,747,173.78, with women benefitting the most from the intervention (73%). For beneficiaries, estimation of attribution, duration, and financial value of these outcomes by the beneficiaries was difficult and variable. Though beneficiaries provided insight for subsequent literature search for values. SROI ratio was calculated as £11.02: £1 and net SROI was £10.02: £1. The payback period for the investment was about one month. Based on the multiple one-way sensitivity analyses, the intervention guaranteed VfM in all scenarios except when all the trainers were paid consultancy fees and the least amount of outcomes occurred. Implications for policy and research: SROI provides critical additional insight when used to assess value-for-money of EmOC training. However, there are methodological improvements required. In implementing and researching EmOC training, consideration needs to be given to both intended positive and unintended negative outcomes of the intervention. Evidently, to achieve the best results from training, other factors such as optimal human resource distribution and availability of equipment need to be addressed. Use of volunteer trainers, particularly those who work locally, to deliver the training is a critical driver in achieving value-for-money for investments made.