Social Return on Investment (SRO) of the Baby Friendly Community Initiative in Kenya Elizabeth W Kimani-Murage1, Sophie Goudet2, Caroline W. Wainaina1, Teresia N. Macharia1, Milka N. Wanjohi1, Frederick M. Wekesah1, Peter Muriuki1, Ruthpearl Ngángá1, Daniel Adero1, Paula L. Griffiths2 and Betty Samburu3 1African Population and Health Research Centre, 2.Loughborough University, 3.Ministry of Health, Kenya, Aim: To determine the effectiveness of personalised home-based counselling on infant feeding practices and consequently morbidity and nutritional outcomes in two Nairobi slums Secondary Outcomes: Nutritional status

Presentation Outline MIYCN Project overview SROI analysis on the MIYCN project Recommendations

The MIYCN Project 2012-2015 Goal: to improve nutritional status and health of children in urban slums Primary outcome: Increased rate of exclusive breastfeeding for six months Aim: To determine the effectiveness of personalised home-based counselling on infant feeding practices and consequently morbidity and nutritional outcomes in two Nairobi slums Secondary Outcomes: Nutritional status

MIYCN Cluster-Randomized Trial 14 Community Units (Viwandani & Korogocho) Intervention Control 529 Mother-child Pairs 581 Mother-child Pairs   CHVs MIYCN counseling Standard care counseling Information Materials Incentives for CHVs CHVs Standard care counselling Information Materials Incentives for CHWs

Exclusive breastfeeding Key results Exclusive breastfeeding Stunting -6-12 months Pre-intervention study EBF 2% (2007 – 2011) Pre-intervention study Stunting 33% (2007 – 2011) Intervention EBF 55.2% Intervention Stunting 30% Control EBF 54.6% Control Stunting 38% P>0.05 i.e. Not statistically significant P<0.05 i.e. Statistically significant

The SROI approach “Measure what is measureable, and make measurable what is not so” Galileo As you can see Galileo is the godfather of SROI. He was not only a renaissance man, he was a SROI man. Unfortunately none of his drawings on cost benefit models survived so the task of working out how you ‘make measurable what is not so’ has been left to contemporary evaluation theorists and practitioners. In a way, SROI attempts to pick up where Galileo left off

What is SROI? Approach of evaluation that aims to account for non-financial outcomes using monetary values to represent them. Gives voices to the people impacted in the intervention Explores unintended outcomes Values non-financial outcomes Values non financial outcomes/changes for identified stakeholders

How is SROI Implemented Establishing scope and identifying key stakeholders Mapping outcomes Evidencing outcomes and giving them a value Establishing impact Calculating the SROI Reporting, using and embedding “1 Establishing scope and identifying key stakeholders. It is important to have clear boundaries about what your SROI analysis will cover, who will be involved in the process and how. 2 Mapping outcomes. Through engaging with your stakeholders you will develop an impact map, or theory of change, which shows the relationship between inputs, outputs and outcomes. 3 Evidencing outcomes and giving them a value. This stage involves finding data to show whether outcomes have happened and then valuing them. 4 Establishing impact. Having collected evidence on outcomes and monetised them, those aspects of change that would have happened anyway or are a result of other factors are eliminated from consideration. 5 Calculating the SROI. This stage involves adding up all the benefits, subtracting any negatives and comparing the result to the investment. This is also where the sensitivity of the results can be tested. 6 Reporting, using and embedding. Easily forgotten, this vital last step involvessharing findings with stakeholders and responding to them, embedding good outcomes processes and verification of the report.” (Lawlor, Neitzert, & Goodspeed, 2012. p 8 -9)

SROI analysis on the MIYCN project Identify the appropriate balance between structure and flexibility. Too much flexibility results in chaos, too much structure results in lifeless communications.

Rationale of MIYCN-SROI 2. What these impacts are worth to the key Stakeholders 1. To find out what MIYCN intervention outcomes impacted on key stakeholders

Methods : Identified Stakeholders Mothers involved in the intervention Fathers of children involved in the intervention Children in the intervention and siblings Grandmothers of children involved in the intervention: caretaker Health care providers in the community Traditional birth attendants Ministry of Health Community Health Workers Data collection team: community members Day care centres managers Local community leaders

Methods: Establishing the impacts and their value Qualitative Interviews (FGDS, IDIS, KIIS) with stakeholders to determine outcomes Quantitative study using questionnaires to quantify and value outcomes Value games to value the outcomes without monetary values

Results: Outcomes

Mothers Outcome Comments Empowerment & increased confidence to make appropriate MIYCN related decisions Reduces risky behavior “When I gave birth, my husband told me that I should stop working until the baby is 2 years, so my mother-in-law was asking, ‘Is the baby an egg that he should be breastfed for 2 years?’ She said that when the navel heals, the baby should stop breastfeeding. So based on what we were taught by the CHW, his father refused, so we decided that the baby breastfeeds for 6 months and then he starts eating, and then he continues to breastfeed until 2 years and put my job aside”. (Mother, Urban Slums) As a result of the counselling, mothers reported to be more knowledgeable and skillful in MIYCN and child care practices, and hence, they were more confident, able to overcome negative pressure from family members like grandmothers (their mothers/mothers-in-law) that in the past led to suboptimal feeding practices.  Improved infant feeding practices & hygiene Improved health seeking behavior

Fathers Outcome Comments Improvement in male involvement in child care Improved relationships Dispelling myths Improved hygiene “It was excellent because not many people feel that the father should also take care of the baby, people just think it’s the mother…” “I was taught….and I was told to at least be participating also…..” (IDI Father Viwandani) But after being taught I felt that is stupidity, its diarrhea and if you keep your child clean it can’t diarrhea all the time and that will eliminate conflicts of unfaithfulness between a husband and a wife in the house” (FGD mothers). More involvement in family planning More productivity and wellbeing and improved living standards Reduced illnesses Decreased health expenditure

Children Outcome Comments Reduced illness and malnutrition “We used to go to hospital often and spend money that was not to be spent... In a month I would take the child to hospital two or three times and I would pay not less than ksh.500 or ksh.1000, so I feel that it did boost me” (IDI father) Better developmental milestones “Yes I have seen changes because that child, even people ask me “why is your child growing so fast?” because right now s/he is a half a year and s/he is walking and I told them it is the mother who used to teach me (CHW)”(FGD mothers)

Grandmothers Outcome Comments Less burden of care More responsible young mothers “It has helped me too because if it was not for the teachings, I would not be going to my work, I would be at home because I am taking care of that child, she (my daughter) didn’t know how to wash her child but she was taught what to do…So it has helped me” (FGD Grandmothers). Improved health

CHVs Outcome Comments Increased psychosocial and financial stress for CHVs “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/the team leader 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)

Day care centers Outcome Comments Increased expenditure “The change that I got is hygiene, we didn’t have proper toilets, so we were forced to look for somewhere to take them where they can go to the toilet although paying is the hard because the place is expensive… but it will force me to stay there because that is the place that is suitable for children” (KII Daycare owner).

Health care providers Outcome Comments Increased workload  “like the workload increased because we never used to have a nutrition clinic. Whoever was there used to come out of that place very tired, tired fatigued, you just want to go home and rest for the rest of the day, so actually it was not a negative whatever it was just a challenge and I guess that is why somebody had to be sent to do his/her work so that I can do my immunization job” Nurse Urban slums.

Social Return Calculation SROI measures the value of social benefits created by an organisation, in relation to the relative cost of achieving those benefits, expressed in a SROI ratio: SROI ratio = present value value of inputs

Social Return Calculation SROI ratio = USD$ 71:1

RECOMENDATIONS 1.BFCI - a priority health promotion tool 2.Support the community health strategy 3. Include fathers in BFCI

Acknowledgements