This guest blog is by Dr Paula Griffiths, Loughborough University. Paula is Co-investigator on the MIYCN-SROI project. The study discussed was hosted and led by APHRC, Nairobi. The Lead researcher is Dr Elizabeth Kimani-Murage.
This research blog contains the personal views of Dr Paula Griffiths on the SROI process and outcomes. The views expressed do not necessarily reflect the funders or host institutions’ official policies.
Early nutrition is critical for later health and sustainable development. The first 1000 days of life (conception to 2 years) have been highlighted as a critical window for developing good health. Promoting optimal early infant feeding practices, particularly for infants living in the poorest and most vulnerable environments has massive potential to support optimal growth and development and to improve later health outcomes. We set out in collaboration with the Kenyan government’s Unit of Nutrition and Dietetics and the Unit of Community Health Services to implement a study to determine the potential effectiveness of the Kenyan Community Health Strategy (proposed as the structure under which to implement the Baby Friendly Community Initiative-BFCI) in promoting exclusive breastfeeding (EBF) in urban poor settings in Nairobi, Kenya (Funded by The Wellcome Trust, UK).
1100 women from Korogocho and Viwandani slums in Nairobi Kenya were recruited during pregnancy and followed up until their babies were one year old. The mothers received regular, personalised, home-based nutritional counselling by Community Health Volunteers (CHVs). The intervention was evaluated for effectiveness using the cluster-randomized controlled study design involving an intervention and a control group. The study observed reported increases in EBF from 2-55% during the intervention in both groups but success came from employing CHVs in both the control and intervention group, which made evaluation of the intervention success more difficult using a conventional cluster randomized control study analysis. The prevalence of stunting for children aged 6-12 months reduced from about 33% at baseline to about 30% in the intervention group, while this increased to 38% in the control group.These improvements were extremely positive but interviews with our project participants were suggesting that the benefits of the intervention went beyond the increases in our target primary outcome of exclusive breastfeeding and the secondary outcomes regarding nutritional outcomes that had been observed. We had intended to evaluate the cost effectiveness of the intervention, but we then learned about an evaluation that goes beyond a pure cost effectiveness analysis to also value and identify the wider social benefits known as Social Return on Investment (SROI) evaluation. We believed that this type of evaluation would be important given the reports we had been hearing from participants about the intervention’s wider benefits. With support from the research consortium Transform Nutrition (funded by the UK Department for International Development (DFID)) we embarked on an SROI evaluation of the intervention.
A short report of the main findings has been published. The current blog picks out some of the key findings of this SROI evaluation and focuses on what health care providers identified as costs and benefits of the intervention.
- The SROI evaluation approach gave voices to mothers, grandmothers, fathers and other stakeholders including: community health volunteers, health workers, day care centre owners, and community leaders who were indirectly impacted by the intervention (to hear voices of others besides the health workers presented in this blog read the SROI Short Report and the BFCI Policy Brief, and watch a video).
- The total intervention cost (including cost to the implementer and stakeholders) was US$ 420,000. Stakeholders valued the outcomes at US$ 8 million (resulting in an SROI ratio (present value of the outcome/total cost of input) of US$ 71:1. This means that for every one dollar spent on the intervention, there were 71 dollars of social value created for 5 years).
- Stakeholders in the intervention identified both unintended benefits as well as some negative outcomes of the intervention that will be important for future similar interventions and government programmes to consider.
Perspectives of healthcare providers
This blog gives a voice to healthcare providers who were one of the stakeholders involved in the intervention. According to the healthcare providers interviewed in the SROI, the intervention had quite a number of unintended benefits to the study stakeholders. These benefits are not only to the mothers and children but spread well beyond those directly targeted by the intervention. Some of the identified benefits by the healthcare providers include:
- Mothers were helped to know more about the health facility and the services it offers. The community knowing about the need to seek healthcare has led to an increase in the number of people who come for check-ups which has translated to increased treatment and also improved prevention measures
- Some of the healthcare providers who were also nutritionists indicated that the work that the CHVs did in counselling mothers in the community helped in capturing malnutrition cases earlier and reduced severe malnutrition cases and associated health issues. This also meant that infants got access to the correct health services quickly.
- The intervention helped CHVs to become empowered especially in being the link between the community and the health care services
- Mothers began to see the importance of using the health care facilities beyond an infant having its final immunization at 9 months because the CHVs counselled them on the importance of using the health facilities up to 5 years. Using facilities for longer means that children can be offered vitamin A and continued growth monitoring for longer. It also offers opportunities to give relevant public health messages.
- More women attended a higher number of ANC visits because the CHVs counselled them on the importance of receiving ANC.
- There was increased workload for health workers, but this helped health workers to leverage for other services e.g. increased demand resulted in maternity services set up by government with equipment supported by NGOs. Increased use of health facilities also led to increased staffing of health facilities because increased numbers meant that extra staffing resources could be requested.
The SROI also identifies unintended negative consequences. The healthcare workers were also able to voice these. The main negative consequence identified was
|· Increased psychosocial and financial stress for CHVs because some participants were living in extreme poverty in very difficult circumstances and CHVs felt obliged to help them financially or socially when difficult situations arose. To give an example of this:|
|“You go to counsel a mother and she tells you ‘I even did not eat, I slept hungry’ So I used to be forced to call my supervisor because at times I did not have money, …So we were forced to contribute and give her. Maybe the mother has three days since delivery, you cannot tell her to go and work. So you will have to support her…. So it was a big change that I did not expect” (FGD, CHVs, Nairobi Slums)
This all adds up to show that this intervention may have had more benefits for infant and young child health and their mothers and other community members than the intended positive benefits associated with the large increase in EBF reported by study participants. Nevertheless from the health workers perspective there were also negative consequences associated with the extreme poverty in which the participants live. Future development of the BFCI programme needs to consider how to ensure that the most vulnerable women working in informal sectors without provision for maternity pay can be assisted by government social security mechanisms. The evidence from this study strongly endorses the idea of supporting baby friendly community initiatives for the urban poor in Kenya. This is timely as the Ministry of health has proposed adoption of the baby friendly community initiative (BFCI) with the National Nutrition Action Plan 2012-2017.