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Background Increased scarcity of public resources has led to a concomitant drive to account for value-for-money of interventions. Traditionally, cost-effectiveness, cost-utility and cost-benefit analyses have been used to assess value-for-money of public health interventions. The social return on investment (SROI) methodology has capacity to measure broader socio-economic outcomes, analysing and computing views of multiple stakeholders in a singular monetary ratio. This review provides an overview of SROI application in public health, explores lessons learnt from previous studies and makes recommendations for future SROI application in public health. Methods A systematic review of peer-reviewed and grey literature to identify SROI studies published between January 1996 and December 2014 was conducted. All articles describing conduct of public health SROI studies and which reported a SROI ratio were included. An existing 12-point framework was used to assess study quality. Data were extracted using pre-developed codes: SROI type, type of commissioning organisation, study country, public health area in which SROI was conducted, stakeholders included in study, discount rate used, SROI ratio obtained, time horizon of analysis and reported lessons learnt. Results 40 SROI studies, of varying quality, including 33 from high-income countries and 7 from low middle-income countries, met the inclusion criteria. SROI application increased since its first use in 2005 until 2011, declining afterwards. SROI has been applied across different public health areas including health promotion (12 studies), mental health (11), sexual and reproductive health (6), child health (4), nutrition (3), healthcare management (2), health education and environmental health (1 each). Qualitative and quantitative methods have been used to gather information for public health SROI studies. However, there remains a lack of consensus on who to include as beneficiaries, how to account for counterfactual and appropriate study-time horizon. Reported SROI ratios vary widely (1.1:1 to 65:1). Conclusions SROI can be applied across healthcare settings. Best practices such as analysis involving only beneficiaries (not all stakeholders), providing justification for discount rates used in models, using purchasing power parity equivalents for monetary valuations and incorporating objective designs such as case–control or before-and-after designs for accounting for outcomes will improve robustness of public health SROI studies.

ObjectivesThe COVID-19 pandemic affected provision and use of maternal health services. This study describes changes in obstetric complications, referrals, stillbirths and maternal deaths during the first year of the pandemic and elucidates pathways to these changes.DesignProspective observational mixed-methods study, combining monthly routine data (March 2019–February 2021) and qualitative data from prospective semi-structured interviews. Data were analysed separately, triangulated during synthesis and presented along three country-specific pandemic periods: first wave, slow period and second wave.SettingSix referral maternities in four sub-Saharan African countries: Guinea, Nigeria, Tanzania and Uganda.Participants22 skilled health personnel (SHP) working in the maternity wards of various cadres and seniority levels.ResultsPercentages of obstetric complications were constant in four of the six hospitals. The percentage of obstetric referrals received was stable in Guinea and increased at various times in other hospitals. SHP reported unpredictability in the number of referrals due to changing referral networks. All six hospitals registered a slight increase in stillbirths during the study period, the highest increase (by 30%–40%) was observed in Uganda. Four hospitals registered increases in facility maternal mortality ratio; the highest increase was in Guinea (by 158%), which had a relatively mild COVID-19 epidemic. These increases were not due to mortality among women with COVID-19. The main pathways leading to these trends were delayed care utilisation and disruptions in accessing care, including sub-optimal referral linkages and health service closures.ConclusionsMaternal and perinatal survival was negatively affected in referral hospitals in sub-Saharan Africa during COVID-19. Routine data systems in referral hospitals must be fully used as they hold potential in informing adaptations of maternal care services. If combined with information on women’s and care providers’ needs, this can contribute to ensuring continuation of essential care provision during emergency.

Background Adolescent mothers aged 15–19 years are known to have greater risks of maternal morbidity and mortality compared with women aged 20–24 years, mostly due to their unique biological, sociological and economic status. Nowhere Is the burden of disease greater than in low-and middle-income countries (LMICs). Understanding factors that influence adolescent utilisation of essential maternal health services (MHS) would be critical in improving their outcomes. Methods We systematically reviewed the literature for articles published until December 2015 to understand how adolescent MHS utilisation has been assessed in LMICs and factors affecting service utilisation by adolescent mothers. Following data extraction, we reported on the geographical distribution and characteristics of the included studies and used thematic summaries to summarise our key findings across three key themes: factors affecting MHS utilisation considered by researcher(s), factors assessed as statistically significant, and other findings on MHS utilisation. Results Our findings show that there has been minimal research in this study area. 14 studies, adjudged as medium to high quality met our inclusion criteria. Studies have been published in many LMICs, with the first published in 2006. Thirteen studies used secondary data for assessment, data which was more than 5 years old at time of analysis. Ten studies included only married adolescent mothers. While factors such as wealth quintile, media exposure and rural/urban residence were commonly adjudged as significant, education of the adolescent mother and her partner were the commonest significant factors that influenced MHS utilisation. Use of antenatal care also predicted use of skilled birth attendance and use of both predicted use of postnatal care. However, there may be some context-specific factors that need to be considered. Conclusions Our findings strengthen the need to lay emphasis on improving girl child education and removing financial barriers to their access to MHS. Opportunities that have adolescents engaging with health providers also need to be seized. These will be critical in improving adolescent MHS utilisation. However, policy and programmatic choices need to be based on recent, relevant and robust datasets. Innovative approaches that leverage new media to generate context-specific dis-aggregated data may provide a way forward.

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.