The impact and social return on investment (SROI) of health workforce training in fragile, conflict-affected settings—a study of the Maridi Health Sciences Institute (MHSI) in South Sudan

Introduction

Background

Health workforce development has long been recognized as one of the key strategies for strengthening health systems. Increasing the number, capacity, and retention of the healthcare workforce has been a challenge for high-, middle- and low-income countries across the globe, and the challenges have been even more pronounced in low-income, fragile and conflict-affected settings. While several policies and programs have been implemented for health workforce development, a lack of evidence persists regarding how to successfully operationalize such initiatives, particularly in fragile and conflict-affected settings, and what the full impacts of such initiatives are.

The Republic of South Sudan (SS) is one of the most fragile countries in the world and continues to be affected by conflict, insecurity and high rates of poverty (1). The primary healthcare system in SS faces critical challenges across various areas, which hinder the effective provision of essential healthcare services, exacerbating the country’s already fragile health system (2-6).

The primary healthcare service delivery in SS is plagued by multiple issues, including limited accessibility, inadequate infrastructure, and substandard quality of care. Many remote areas lack proper healthcare facilities, leading to restricted access to essential services for a significant portion of the population. Moreover, the existing healthcare infrastructure often suffer from insufficient equipment, medical supplies, and maintenance, undermining the delivery of timely and effective care. Additionally, the quality of healthcare services provided in many primary care facilities is subpar, lacking proper standards, protocols, and skilled healthcare professionals (7-13).

South Sudan is faced with a severe shortage of qualified and skilled healthcare professionals. The limited number of trained doctors, nurses, and other healthcare workers hinders the delivery of comprehensive and timely healthcare services to the population. The shortage is further exacerbated by the uneven distribution of healthcare professionals, with most being concentrated in urban areas, leaving rural and remote regions underserved. Moreover, the lack of incentives, professional development opportunities, and inadequate compensation for healthcare professionals contributes to high attrition rates, making it challenging to retain and motivate skilled workers in the primary healthcare sector (14,15).

The country lacks well-equipped and adequately staffed training institutions for training healthcare professionals, hindering the education and skill development of future healthcare providers. At the policy level, the laws guiding the operations of the health training institutions remain unclear. The scarcity of training facilities limits the number of healthcare professionals being trained, leading to a shortage of qualified personnel in the primary healthcare sector. Coupled with inadequate training facilities, poor governance undermines the capacity to train healthcare workers on up-to-date techniques, protocols, and best practices, hindering the overall quality of care provided in primary healthcare facilities.

Rationale and knowledge gap

While increasing the number, capacity, and retention of the healthcare workforce has been a clear priority for countries across the globe, there remains a need for more knowledge and evidence on how to successfully do that, and particularly in fragile and conflict-affected settings such as South Sudan (16). Furthermore, a lack of evidence persists as to the full impacts of successful health workforce development initiatives. More often than not, evaluation studies have focused on the outputs of interventions such as the increased number of health workers trained or available and the increased number of health visits. These evaluations typically have not measured the wide-range of impacts across society and long-term value resulting from such interventions.

In 1998, Amref Health Africa (Amref) in South Sudan collaborated with the national Ministry of Health to open the Maridi Health Sciences Institute (MHSI). Despite South Sudan at the time being in the middle of a civil war, the Institute was established with support from Amref, Italy, United States Agency for International Development (USAID) and other funders with the main aim of helping to rebuild the South Sudan health system through training of mid-level cadres of health workers that were desperately needed to deliver the minimum package of health services as aspired for in the then National Health Policy of South Sudan. From 1998, Amref in Italy supported the MHSI with full scholarship for clinical officers, public health officers, community health workers. In 2006 other donors such as European Union, Global Affairs Canada (GAC) Swedish International Development Agency (SIDA) through United Nations Population Fund (UNFPA), came in to collaborate with Amref in South Sudan by introducing additional courses such as community midwifery, public and environmental health officers in 2009 [Multi-Donor Trust Fund (MDTF)], while training of enrolled and registered midwives followed in 2012.

From the start of January 1998 to December 2022, tuition and subsistence support was offered 100% free to students who enrolled for a course at the institute. Whereas MHSI traditionally operated on a full scholarship, full residential model, funding constraints have necessitated the need for cost effective approaches. Currently, the Institute has a capacity of over 450 students and offers more courses on a hybrid model where both residential and non-residential students are enrolled and more courses are offered. The health workers training curriculum in South Sudan is accredited by the Ministry of Health and other professional bodies. The training prepares the graduates to practice independently.

Since its inception, MHSI has enrolled 1,101 students who had completed secondary education and met the minimum requirements. Out of these, 991 (706 males; 285 females) graduated successfully, all of whom were 18 years and older. This represents 90% success rate among students. The distribution of MHSI graduates include the following cadres: clinical officers 643 (561 males; 82 females), registered midwives 164 (83 males; 81 females), enrolled midwives 68 (20 males; 48 females), community midwives 101 (31 males; 70 females), public and environmental health officers 15 (11 males; 4 females).

Over the 24-year period of training, MHSI has remained a center of excellence for the pre-service (foundational training one receives prior to beginning their work in a particular field) health workforce production in South Sudan. The skilled health workers from MHSI have been posted in health facilities across the country to address the problem of health workers shortages. One of the key innovative strategies used to sustain quality and excellence at MHSI was continuous refresher courses for the teaching staff, which ensured that the faculty was kept up to date on key materials and topics. Also, MHSI established strong relationships with a network of clinical practicum sites, by frequently providing relevant commodities required to deliver quality training to the students. The above best practices enabled the students to interact with the right materials and content during training, while also achieving better retention levels for the qualified teaching staff. The training equipped the health workers with the necessary skills to work in resource poor and conflict prone environment.

Objective

This study presents the MHSI in South Sudan, including the context in which this health workforce training intervention was started, how it has evolved over time, and evidence of its impact, including its social return on investment (SROI).

The specific objectives of the study included: (I) to establish the outcomes of the pre-service training program at MHSI in SS from the perspectives of different key stakeholder groups (i.e., health care workers, their communities, state and local institutions including the Ministry of Health and the private sector); (II) to determine the value, including the SROI, of the pre-service training program at MHSI; and (III) to establish the overall impact of the pre-service training program at MHSI.

The evaluation was guided by the following questions:

• Who are the key stakeholders of the intervention?
• What outcomes do key stakeholders experience?
• What is the relative value of the outcomes to key stakeholders?
• What is the SROI of the intervention?

Methods

This study utilized the internationally recognized approach to SROI analysis as articulated by Social Value International (17) to conduct the evaluation of this intervention. SROI is a mixed methods approach, similar to cost-benefit analysis but necessitates the engagement of key stakeholders throughout the measurement and analysis process. SROI measures changes that are relevant to the people that contribute to and experience them by capturing the value of social, economic, and environmental outcomes, and uses monetary values to represent these outcomes (17). SROI analysis is increasingly being used to measure the impact of public health interventions (18-24).

This study included a stakeholder-centric mixed-methods approach including document review and qualitative and quantitative data collection to generate credible evidence to answer the evaluation questions. This included 15 focus group discussions (FGDs), 41 key informant interviews (KIIs) and quantitative surveys with key stakeholders.

Data was collected from the following 5 counties: Juba, Maridi, Yambio, Bor and Tonj and specifically from the following sites: MHSI, Maridi Hospital, Yambio State Hospital, Juba Teaching and Referral Hospital, communities within the catchment population of the above hospitals, South Sudan Nurses and Midwives Association (SSNAMA), State Ministry of Health Western Equatorial State and Maridi County Health Departments. The identified hospitals were included because they have the majority share of graduates from MHSI working there.

The purpose of the qualitative focus groups and interviews was to understand from stakeholders’ perspectives what were the key outcomes they experienced as a result of the intervention, how they described the changes experienced, how long outcomes lasted (duration), their relative importance or value, what would have happened anyway without the intervention (deadweight), how much of the outcomes they experienced they would attribute to the intervention (attribution), if the outcomes dropped off over time (drop-off), and any recommendations they have for the future.

The qualitative data was collected from samples of key stakeholders between September 2023 and December 2023, after which, transcripts were transcribed and translated from Juba Arabic to English where necessary and then coded in NVivo 14 and analyzed according to thematic analysis. The findings from the qualitative analysis informed the development of the quantitative survey tools.

Quantitative data was collected between January and March 2024 through surveys of key stakeholders who were most materially affected and had large numbers of people affected to obtain more representative samples, in accordance with the resources available to conduct the data collection. A total of 596 surveys were completed by graduates, community members and program staff. The data was cleaned, then analyzed using Excel software to determine the extrapolated quantity of people within each stakeholder group experiencing each outcome, percentages for deadweight, attribution, and drop-off for each outcome, and the relative value of outcomes from stakeholders perspectives.

The outcomes identified by key stakeholders were monetized using two different approaches to valuation: cost-based valuation using financial proxies primarily sourced from existing literature including government reports (often the technique employed in economic evaluations) and stakeholders’ revealed preference valuation to understand the relative value of outcomes from their perspectives. Where information on financial proxies was not available in the literature, the research team used the market price method to assign values (i.e., how much would it cost to purchase an experience that leads to similar outcomes). Financial values from the literature were adjusted for time horizon and contextualized as relevant. For the stakeholders revealed preference valuation, data was collected on the relative importance expressed during surveys and then anchored to literature values. The monetized values of outcomes were used in the calculation of the SROI ratio.

In addition to accounting for the monetized value of outcomes, calculating the SROI involved accounting for the quantity of people experiencing the outcomes, deadweight, attribution, and drop-off to determine the total value of each outcome, and applying a discount rate. The total value of all outcomes (i.e., impacts) was summed up and divided by the total investment to arrive at the SROI ratio. Sensitivity analysis was conducted to determine the effects of key factors on the SROI results, including testing for how a fifty percent increase and fifty percent decrease in each of deadweight, attribution, drop-off, quantity of people experiencing the outcome, and financial proxies affected the SROI results.

Validation sessions were conducted via virtual meetings with key stakeholders to share initial findings about the outcomes and their relative values and ensure the analysis mirrored their experiences; followed by revisions to the analysis as necessary. Final results were shared with key stakeholders beginning in June 2024, including a discussion of how results can be used and recommendations for future programming to grow social value creation.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Research Ethics Review Board of the Ministry of Health of The Republic of South Sudan (No. MOH/RERB/P/50/21/08/2023-MOH/RERB/A/50/30/08/2023) and informed consent was obtained from all individual participants.

Results

Key stakeholders of the pre-service training at MHSI

The study identified key stakeholders of the intervention as those who participated in programming, those who were involved with the coordination and delivery of the programming, and any other parties who were significantly affected by MHSI. To ensure that stakeholders or sub-groups of stakeholders were not missing, participants were asked during qualitative data collection to identify other groups who they felt may be affected by the programming. The key stakeholders identified were graduates of MHSI, community members in the catchment areas where MHSI graduates are largely employed, government (national and local), private employers, SSNAMA, board members of MHSI, program staff and donors (see Figure 1).

Figure 1 Key stakeholders of MHSI. MHSI, Maridi Health Sciences Institute; NGO, Non-Governmental Organization; SSNAMA, South Sudan Nurses and Midwives Association.

Outcomes experienced by the stakeholders and their relative value

The key stakeholders experienced several outcomes (see Figure 2). Graduates experience of increased professionalism and skills was the most valuable outcome for them, followed by increased employment. Other outcomes experienced by the graduates were increased ability to pursue further education, improved relationship with family and the community, a negative outcome of increased separation from family and the community (during training and employment given the respective locations), and increased safety and security during times of conflict.

Figure 2 Outcomes experienced by key stakeholders of MHSI. Amref, Amref Health Africa; MHSI, Maridi Health Sciences Institute; NGO, Non-Governmental Organization; SSNAMA, South Sudan Nurses and Midwives Association.

Community members experience of improved quality of care was the most valuable outcome for them, followed closely by reduced under-5 mortality. The other outcomes experienced by community members, in order of relative value, included reduced infant mortality, increased knowledge of family planning, reduced maternal mortality and increased access to care.

Government officials both at national and county level experienced improved administration and delivery of training and education as the most valuable outcome to them, followed by improved quality of care delivered.

The program staff at MHSI experienced increased professional reputation as the most valuable outcome to them, followed by increased professional development. Other outcomes experienced by the program staff included increased job satisfaction and increased safety and security during times of conflict.

In addition to the relative value of outcomes established using cost-based valuation, two key stakeholders, MHSI graduates and community members, were engaged in a valuation exercise to reveal the relative value of outcomes they experienced from their perspectives (stakeholders revealed preferences valuation). MHSI graduates most valued their increased professionalism and skills (consistent with the cost-based valuation), while community members most valued their increased access to care, relative to the other outcomes that each experienced.

The SROI of the pre-service training at MHSI

Findings suggest a very strong positive impact of the intervention. Results of the cost-based approach to valuation using financial proxies primarily sourced from existing literature (see Table 1) found an SROI ratio of 1:11, meaning for every $1 invested in the intervention, it generated $11 in social value, with a sensitivity analysis range from $5–$37 (see Table 2).

Outcomes durations after any form of engagement with MHSI

The stakeholders noted that most of the outcomes lasted for long durations after their experience with MHSI ended. Increased knowledge of family planning lasted for about 11 years among community members, improved relationship with family and community members lasted for about 10 years among the MHSI graduates, and increased separation from family and community, increased ability to pursue further education, increased professionalism and skills, increased access to care and increased quality of care received all lasted for about 9 years.

Discussion

Key findings

Through the SROI analysis process, key stakeholders who had affected or been affected by the intervention were identified. Findings from engagement with key stakeholders via focus groups, KIIs, and surveys, revealed several positive outcomes resulting from the intervention (see Figure 2). According to the cost-based approach to valuation, for every $1 invested in the intervention, it generated $11 in social value.

Strengths and limitations

Key strengths of this study are that it is one of the first studies to measure the wide-ranging impact of a successful health workforce development intervention in the fragile, conflict-affected setting of South Sudan, including its SROI. Results of the SROI evaluation can be used to understand the impact and long-term value of the intervention, including but not limited to understanding what outcomes mattered most to key stakeholders, including tangible and intangible outcomes, and opportunities to increase value for different stakeholder groups in the future.

Results of the SROI analysis also demonstrate the added value of this approach over current approaches to evaluation traditionally used in health and development, including but not limited to its encouragement of decision-making based on value, not outputs. Outputs do not reflect the whole picture but have often been the basis for many decisions in these sectors.

There are a few limitations of this study. Historical and environmental factors limited data collection as contact information/records had been destroyed prohibiting the research team from reaching a statistically representative sample of MHSI graduates, necessitating a snowball sampling approach. Furthermore, while community members served by MHSI graduates may be living in various locations within South Sudan, this analysis only engaged community members currently living in the catchment areas of Western Equatoria, Central Equatoria, Warrap and Jonglei states. It was not feasible to survey all patients everywhere served by MHSI graduates nor would these outcomes likely make a material difference to the results, though a random sampling approach was successfully used to engage with community members and a representative sample was reached. This evaluation did not use a randomized control trial methodology to tease out attribution and displacement, though estimates of both were taken into account in the SROI calculation. Additionally, recall bias and halo bias may have played a role in respondents’ responses as is the case with most program evaluations which engages stakeholders. Finally, there were limitations in calculating the SROI results through stakeholder revealed preferences valuation as data was only available for some outcomes and some stakeholders, so the research team agreed to rely on the SROI results obtained through cost-based valuation using literature as the more reliable and credible SROI ratio.

Comparison with similar research

Consistent with existing research, this study found significant benefits resulting from investing in a health workforce development intervention (25,26). In addition, World Health Organization (WHO) has documented that for every US$1 invested in health and sustaining the jobs of health workers, the potential return is as much as US$9 (27). This is one of the first studies to identify and measure the wide range of outcomes of health workforce interventions as experienced by various key stakeholders, and the value of those changes, over a 20+ year period, including the SROI. To the knowledge of the authors, this is the first SROI study conducted in South Sudan, and one of the few SROI studies of health workforce development anywhere.

Explanations of findings

Findings suggest that MHSI has had a strong positive and long-term impact on its stakeholders and in strengthening South Sudan’s health system overall. Results also shed insight on the value-for-money of the intervention. The contribution of nearly 1,000 health workers to the health system during 1998–2022—a period including war, heightened conflict and insecurity, extreme weather events—and all the contributions these health workers have made and continue to make for the people of South Sudan, is immensely valuable both in the moment and into the future. This was clearly demonstrated by stakeholders’ identification of not only the many positive outcomes they experienced, but how long they lasted. While community members benefitted the most from MHSI, there was clear benefit to all stakeholder groups including graduates, employers, SSNAMA, the government, donors, Amref program staff, and Amref overall as an organization.

Implications and actions needed

Findings from the impact evaluation highlight seven key actions points and recommendations that could increase the impact of MHSI’s training programs and social value in the future. They include:

• MHSI should seek increased investment and long-term funding commitments from government, donors, and private sector partners to expand its programs and scale its impact, based on its demonstrated ability to generate significant social value.
• MHSI should expand opportunities for students to connect with employers to aid in their job placement immediately upon graduation.
• MHSI should continue their strong commitment to ensure interested students from various locations across the country have the opportunity to train at MHSI to continue contributing to the improved accessibility, availability and quality of healthcare throughout the country.
• MHSI should explore the possibility of obtaining/upgrading to university status to provide further education and training to students, including specialty training, and the possibility of graduates’ credentials to be recognized and counted towards medical degrees.
• MHSI should continue to serve as a model of excellence for training and provide advisory and support, including the facilitation of regular curricular review, to other training institutes within and outside the country, to enhance training and outcomes throughout the country and region.
• MHSI should explore opportunities for continuing education, networking and professional development of healthcare professionals who graduated from MHSI.
• MHSI should explore the possibility of expansion to a research institute for emerging health issues, and provide relevant and timely training to health workers as health challenges change.

Conclusions

While countries have increasingly recognized the importance of health workforce development in strengthening their health systems, gaps remain in terms of the knowledge and evidence as to successful models of how to operationalize these goals. This gap is particularly pronounced in fragile, conflict-affected settings.

It is hoped that this study can provide insights and evidence of a successful model implemented by the MHSI in South Sudan, along with the long-term value and wide range of impacts of such interventions.

With more information and evidence on what works, countries will be better equipped to implement policies and programming to increase health workforce development and its impacts.

Discussion questions

• What have been the unique and critical challenges facing health delivery in South Sudan?
• How has MHSI successfully addressed some of the critical challenges facing health delivery in South Sudan? What key strategies did they employ?
• How can MHSI continue to stay relevant and operate sustainably?

Acknowledgments

This study was a collaborative effort between Amref, the University of Southern California, and SVT Group. Amref funded the study and partnered in its implementation, working alongside social return on investment (SROI) experts from the University of Southern California and SVT Group.

We thank all stakeholders for their participation and for sharing their experiences. We are especially grateful to the local research assistants who conducted data collection. This study would not have been possible without their efforts. Special thanks go to Achier Adupmou for his support on behalf of the Ministry of Health of South Sudan, and to Samuel Okaro and Taban Patrick of Amref Health Africa – South Sudan for overseeing local data collection and contributing valuable contextual insights.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Case Studies in Global Health Leadership and Management” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-112/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-112/prf

Funding: This work was supported by Amref Health Africa to conduct the impact evaluation.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-112/coif). The series “Case Studies in Global Health Leadership and Management” was commissioned by the editorial office without any funding or sponsorship. Sara Olsen reports that SVT Group was paid by the University of Southern California to assist with study design, instrument design, data analysis, and reporting. SVT Group collaborated with USC and Amref’s staff, who managed data collection, to perform the study. S.K. reports that The University of Southern California was contracted to collaborate with Amref on study design and execution of the study including but not limited to technical expertise on SROI methodology. Amref provided funding for this study. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Research Ethics Review Board of the Ministry of Health of The Republic of South Sudan (No. MOH/RERB/P/50/21/08/2023-MOH/RERB/A/50/30/08/2023) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. WHO. 2022 [cited 2023 Jul 4]. Strengthening primary health care in fragile settings: South Sudan. Available online: https://www.who.int/news-room/feature-stories/detail/strengthening-primary-health-care-fragile-settings-south-sudan
2. WHO, UNICEF, UNFPA, World bank group, united nations population division. Trends in maternal mortality 2000 to 2017: estimates. Sexual and Reproductive Health [Internet]. 2019 [cited 2023 Jul 4];12. Available online: https://www.unfpa.org/sites/default/files/pub-pdf/Maternal_mortality_report.pdf
3. WHO. Global Health Estimates 2019 [Internet]. 2020 [cited 2023 Jul 4]. Available online: https://www.who.int/data/gho/data/indicators
4. Okech O, Duclos D. Roles of local healthcare workers in the humanitarian response in South Sudan: a literature review. South Sudan Medical Journal 2022;2022: [Crossref]
5. CARE International. 2014. CRITICAL DIAGNOSIS: The Case for Placing South Sudan’s Healthcare System at the Heart of the Humanitarian Response. Available online: https://www.care.org.au/wp-content/uploads/2014/12/CRITICAL-DIAGNOSIS.-The-Case-for-Placing-South-Sudans-Healthcare-System....pdf
6. Downie R. The state of public health in South Sudan. Critical Condition, Washington DC: Center for Strategic and International Studies; 2012.
7. Ministry of Health Republic of South Sudan. Health Sector Development Plan 2012-2016. One Maternal Death is one too Many; 2012.
8. Mugo NS, Dibley MJ, Damundu EY, et al. Barriers Faced by the Health Workers to Deliver Maternal Care Services and Their Perceptions of the Factors Preventing Their Clients from Receiving the Services: A Qualitative Study in South Sudan. Matern Child Health J 2018;22:1598-606. [Crossref] [PubMed]
9. Sami S, Amsalu R, Dimiti A, et al. Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: a mixed methods case study. BMC Pregnancy Childbirth 2018;18:325. [Crossref] [PubMed]
10. Jones A, Howard N, Legido-Quigley H. Feasibility of health systems strengthening in South Sudan: a qualitative study of international practitioner perspectives. BMJ Open 2015;5:e009296. [Crossref] [PubMed]
11. Lutwama GW, Sartison LJ, Yugi JO, et al. Health services supervision in a protracted crisis: a qualitative study into supportive supervision practices in South Sudan. BMC Health Serv Res 2022;22:1249. [Crossref] [PubMed]
12. Dulacha D, Ramadan OPC, Guyo AG, et al. Use of mobile medical teams to fill critical gaps in health service delivery in complex humanitarian settings, 2017-2020: a case study of South Sudan. Pan Afr Med J 2022;42:8. [PubMed]
13. Sami S, Kerber K, Tomczyk B, et al. “You have to take action”: changing knowledge and attitudes towards newborn care practices during crisis in South Sudan. Reprod Health Matters 2017;25:124-39. [Crossref] [PubMed]
14. Ministry of Health Republic of South Sudan. National Health Policy 2016-2026. Working Paper; 2016.
15. Campbell J, Dussault G, Buchan J, et al. A universal truth: No health without a workforce. World Health Organization; 2013.
16. Gavine A, MacGillivray S, McConville F, et al. Pre-service and in-service education and training for maternal and newborn care providers in low- and middle-income countries: An evidence review and gap analysis. Midwifery 2019;78:104-13. [Crossref] [PubMed]
17. Social Value International. 2012. The guide to social return on investment (SROI). Available online: https://www.socialvalueint.org/guide-to-sroi
18. Banke-Thomas AO, Madaj B, Charles A, et al. Social Return on Investment (SROI) methodology to account for value for money of public health interventions: a systematic review. BMC Public Health 2015;15:582. [Crossref] [PubMed]
19. Kumar SR, Banke-Thomas A. Social Return on Investment (SROI): An Innovative Approach to Sustainable Development Goals for Sexual and Reproductive Health Programming in sub-Saharan Africa. Afr J Reprod Health 2016;20:85-93. [Crossref] [PubMed]
20. Edwards RT, Lawrence CL. 'What You See is All There is': The Importance of Heuristics in Cost-Benefit Analysis (CBA) and Social Return on Investment (SROI) in the Evaluation of Public Health Interventions. Appl Health Econ Health Policy 2021;19:653-64. [Crossref] [PubMed]
21. Hutchinson CL, Berndt A, Forsythe D, et al. Valuing the impact of health and social care programs using social return on investment analysis: how have academics advanced the methodology? A systematic review. BMJ Open 2019;9:e029789. [Crossref] [PubMed]
22. Banke-Thomas A, Madaj B, van den Broek N. Social return on investment of emergency obstetric care training in Kenya. BMJ Glob Health 2019;4:e001167. [Crossref] [PubMed]
23. Kumar S. Social Return on Investment (SROI) Analysis: An Innovative Framework for Measuring the Impact of One Health. Planet@Risk 2014;2:150-4.
24. Kumar S. Social return on investment (SROI) analysis: A new tool for strategic decision making, planning, and evaluation for managers, investors, and policy makers in international aid and development. Doctoral dissertation, Los Angeles: University of California; 2011.
25. MacGregor RG, Zihindula G, Chola L, et al. The training of healthcare professionals: An expense or an investment? S Afr Med J 2020;110:369-73. [Crossref] [PubMed]
26. Masis L, Gichaga A, Zerayacob T, et al. Community health workers at the dawn of a new era: 4. Programme financing. Health Res Policy Syst 2021;19:107. [Crossref] [PubMed]
27. WHO African Region. 2024 [cited 2025 March 20]. African region’s first-ever health workforce investment charter launched. Available online: https://www.afro.who.int/news/african-regions-first-ever-health-workforce-investment-charter-launched