Social Return On Investment (SROI): Problems, solutions … and is SROI a good investment?

The conclusion of this special issue on Social Return On Investment (SROI) begins with a summary of both advantages and problems of SROI, many of which were identified in preceding articles. We also offer potential solutions for some of these problems that can be derived from standard evaluation practices and that are becoming expected in SROIs that follow guidances from international SROI networks. A remaining concern about SROI is that we do not yet know if SROI itself adds sufficient benefit to programs to justify its cost. Two frameworks for this proposed metaevaluation of SROI are suggested, the first comparing benefits to costs summatively (the resource→outcome model). The second framework evaluates costs and benefits according to how much they contribute to or are caused by the different activities of SROI. This resource→activity→outcome model could enable outcomes of SROI to be maximized within resource constraints (such as budget and time limits) on SROI. Alternatively, information from this model could help minimize the costs of achieving a specific level of return on investment from conducting SROI. Possible problems with this metaevaluation of SROI are discussed.

Valuing the impact of health and social care programs using social return on investment analysis: how have academics advanced the methodology? A systematic review

OBJECTIVES

To identify how social return on investment (SROI) analysis-traditionally used by business consultants-has been interpreted, used and innovated by academics in the health and social care sector and to assess the quality of peer-reviewed SROI studies in this sector.

DESIGN

Systematic review.

SETTINGS

Community and residential settings.

PARTICIPANTS

A wide range of demographic groups and age groups.

RESULTS

The following databases were searched: Web of Science, Scopus, CINAHL, Econlit, Medline, PsychINFO, Embase, Emerald, Social Care Online and the National Institute for Health and Care Excellence. Limited uptake of SROI methodology by academics was found in the health and social care sector. From 868 papers screened, 8 studies met the criteria for inclusion in this systematic review. Study quality was found to be highly variable, ranging from 38% to 90% based on scores from a purpose-designed quality assessment tool. In general, relatively high consistency and clarity was observed in the reporting of the research question, reasons for using this methodology and justifying the need for the study. However, weaknesses were observed in other areas including justifying stakeholders, reporting sample sizes, undertaking sensitivity analysis and reporting unexpected or negative outcomes. Most papers cited links to additional materials to aid in reporting. There was little evidence that academics had innovated or advanced the methodology beyond that outlined in a much-cited SROI guide.

CONCLUSION

Academics have thus far been slow to adopt SROI methodology in the evaluation of health and social care interventions, and there is little evidence of innovation and development of the methodology. The word count requirements of peer-reviewed journals may make it difficult for authors to be fully transparent about the details of their studies, potentially impacting the quality of reporting in those studies published in these journals.

PROSPERO REGISTRATION NUMBER

CRD42018080195.

Health Impact and Social Value of Interventions, Services, and Policies: A Methodological Discussion of Health Impact Assessment and Social Return on Investment Methodologies

Introduction: Assessing the positive and negative impact of policies, services and interventions on health and well-being is of great importance to public health. Health Impact Assessment (HIA) and Social Return on Investment (SROI) are established methodologies which assess potential effects on health and well-being, including social, economic and environmental factors, indicating synergies, and cross-over in their approach. Within this paper, we explore how HIA and SROI could complement each other to capture and account for the impact and social value of an assessed intervention or policy. Methods: A scoping review of academic and gray literature was undertaken to identify case studies published between January 1996 and April 2019 where HIA and SROI methodologies have been used to complement each other previously. Semi-structured interviews were carried out with nine international experts from a range of regulatory and legislative contexts to gain a deeper understanding of past experiences and expertise of both HIA and SROI. A thematic analysis was undertaken on the data collected. Results: The scoping review identified two published reports on scenarios where HIA and SROI have both been used to assess the same intervention. Results from the interviews suggest that both methods have strengths as standalone methodologies. HIAs were noted to be well-structured in their approach, assessing health and well-being in its broadest context. SROI was noted to add value by monetizing social value, as well as capturing the social and environmental impact. Similarities of the two methods was suggested as their strong emphasis on stakeholder engagement and common shared principles. When questioned how the two methods could complement each other in practice, our results indicate the benefits of using HIA as an initial exploration of impact, potentially using SROI subsequently to monetarize social value. Conclusion: HIA and SROI have many synergies in their approaches. This research suggests potential benefits when used in tandem, or combining the methods to assess impact and account for social value. Further research is needed to understand the implications of this in practice, and to understand how the results of the two methods could be used by decision-makers.

The leap from ROI to SROI: Farther than expected?

Social return on investment (SROI) is a popular method for evaluating the impact that organizations have on society and the environment. It has its roots in finance, where return on investment (ROI) is used to evaluate investments. Over the past ten years, SROI has made the leap from a tool for building private wealth to one that advances the public good. Has it landed us in a better place? To answer the question, I describe the general approach to financial analysis, how it is applied to financial decisions, and how it has been adapted to evaluate impact. I then consider the strengths and weaknesses of SROI, and suggest how, by pushing beyond the constraints of financial analysis, it can give stakeholders voice and provide evidence of success from diverse perspectives. Along the way, I propose a conceptual model for value, a foundational concept in SROI that has been criticized by some as underdeveloped, and I include a technical appendix that identifies potential sources of statistical bias in SROI estimates. I conclude by acknowledging our growing need to incorporate efficiency as one of multiple success criteria and the role that SROI-properly implemented-can play.

Social value of a set of proposals for the ideal approach of multiple sclerosis within the Spanish National Health System: a social return on investment study

BACKGROUND

Multiple Sclerosis (MS) is a chronic inflammatory, demyelinating and neurodegenerative disease that in many cases produces disability, having a high impact in patients' lives, reducing significantly their quality of life. The aim of this study was to agree on a set of proposals to improve the current management of MS within the Spanish National Health System (SNHS) and apply the Social Return on Investment (SROI) method to measure the potential social impact these proposals would create.

METHODS

A Multidisciplinary Working Team of nine experts, with representation from the main stakeholders regarding MS, was set up to agree on a set of proposals to improve the management of MS. A forecast SROI analysis was carried out, with a one-year timeframe. Data sources included an expert consultation, a narrative literature review and a survey to 532 MS patients. We estimated the required investment of a hypothetical implementation, as well as the potential social value that it could create. We calculated outcomes in monetary units and we measured intangible outcomes through financial proxies.

RESULTS

The proposed ideal approach revealed that there are still unmet needs related to MS that can be addressed within the SNHS. Investment would amount to 148 million € and social return to 272 million €, so each euro invested could yield almost €2 of social return.

CONCLUSIONS

This study could guide health interventions, resulting in money savings for the SNHS and increases in patients' quality of life.

Multidisciplinary approach to psoriasis in the Spanish National Health System: A social return on investment study

Introduction

Psoriasis is a chronic disease in which patients feel stigmatization, social rejection, and suffer from low self-esteem. There are still unmet needs that make it necessary to define a new multidisciplinary approach to provide benefits not only to patients and their families but also to the Spanish National Health System (SNHS) and society. The aim was to define a new approach to better address the unmet needs of patients with psoriasis within the SNHS and to measure its impact from a social perspective, that is, in clinical, health care, economic, and social terms.

Methods

Multidisciplinary experts identified, agreed on, and selected several health care interventions that were feasible for implementation in the SNHS. This process was carried out in four different areas: diagnosis, mild psoriasis, moderate psoriasis, and severe psoriasis. To estimate investment and social return, the social return on investment (SROI) method was used.

Results

The new approach to psoriasis management in the SNHS comprised 18 proposals. The investment needed for the implementation of this new approach would amount to €222.77 million and its return to €1,123.11 million. This would yield a SROI ratio of €5.04 for every euro invested.

Conclusion

The new approach to psoriasis management would yield a positive social return. The results will allow optimal strategic planning adapted to each assistance situation, to achieve a comprehensive and multidisciplinary approach.

Social Return on Investment (SROI) of mental health related interventions-A scoping review

Background

There is a growing recognition of the need to effectively assess the social value of public health interventions through a wider, comprehensive approach, capturing their social, economic and environmental benefits, outcomes and impacts. Social Return on Investment (SROI) is a methodological approach which incorporates all three aspects for evaluating interventions. Mental health problems are one of the leading causes of ill health and disability worldwide. This study aims to map existing evidence on the social value of mental health interventions that uses the SROI methodology.

Methods

A scoping evidence search was conducted on Medline, PubMed, Google Scholar and relevant gray literature, published in English between January 2000 and March 2021 to identify studies which capture the SROI of mental health interventions in high- and middle-income countries. Studies that reported mental health outcomes and an SROI ratio were included in this review. The quality of included studies was assessed using Krlev's 12-item quality assessment framework.

Results

The search identified a total of 435 records; and 42 of them with varying quality met the study inclusion criteria. Most of the included studies (93%) were non-peer reviewed publicly available reports, predominantly conducted in the United Kingdom (88%); and majority (60%) of those studies were funded by charity/non-for-profit organizations. Out of 42 included studies, 22 were targeted toward individuals experiencing mental health problems and the remainder 20 were targeted to vulnerable groups or the general population to prevent, or reduce the risk of poor mental health. Eighty-one percent of included studies were graded as high quality studies based on Krlev's 12-item quality assessment framework. The reported SROI ratios of the included studies ranged from £0.79 to £28.00 for every pound invested.

Conclusion

This scoping review is a first of its kind to focus on SROI of mental health interventions, finding a good number of SROI studies that show a positive return on investment of the identified interventions. This review illustrates that SROI could be a useful tool and source of evidence to help inform policy and funding decisions for investment in mental health and wellbeing, as it accounts for the wider social, economic and environmental benefits of public health interventions. More SROI research in the area of public health is needed to expand the evidence base and develop further the methodology.

Social Return on Investment (SROI): An Innovative Approach to Sustainable Development Goals for Sexual and Reproductive Health Programming in sub-Saharan Africa

Despite efforts, sub-Saharan Africa did not achieve many key Sexual and Reproductive Health (SRH) targets under the Millennium Development Goals. In the post 2015 era, the Sustainable Development Goals (SDGs) will frame decisions on donor priorities and resource allocations. Successfully addressing SRH challenges in sub-Saharan Africa have been blunted due to fragmentation of SRH interventions in planning and implementation, lack of coherence between policies and program implementation, resulting in poor program performance and lack of accountability. We suggest the Social Return on Investment (SROI) framework offers a strategic approach for sub-Saharan Africa in support of the implementation, monitoring and evaluation of SRH programs given its capacity to capture social and economic impacts, stakeholder participation, and sensitivity towards key human rights concerns relevant to SRH. SROI disrupts a -business as usual‖ approach for one that is systematic, participatory, and supportive of economic and human rights needs for success in the SDG era.

Legitimation dynamics: How SROI could mobilize resources for new constituencies

The following critical essay on the social return on investment (SROI) methodology is broken into two parts. In the first section, focusing on the categorization dynamics of the SROI, I review a set of methodological and ethical tensions surrounding the SROI, using examples from my own work and other published works using SROI. These tensions include the fact that the project requires standardization to achieve comparability while concurrently offering a flexibility in constructing a narrative of impact that is attractive to users. In the second section, focusing on the legitimation dynamics, I define a narrow scope for where, despite the aforementioned pitfalls, that the SROI can be quite effective in building a rhetorical argument for directing material resources. The essay argues that despite ongoing methodological challenges, the investor lens and market logic undergirding the metric provide a powerful frame for persuasion that can be used to construct worthiness and value creation for constituents not already constructed as such.

Self-administered sexual health testing in an open prison setting: a pilot health impact assessment and social return on investment analysis

PURPOSE

The sexual health of the male prison population is often among the poorest in a country. This paper aims to identify the wider health impacts and social value of a sexual health self-sampling programme offered to male prisoners in an open prison setting in Wales.

DESIGN/METHODOLOGY/APPROACH

This study applied a unique pilot approach of using Health Impact Assessment and Social Return on Investment Frameworks in tandem. Key stakeholder groups affected by the intervention were identified, and engaged with through workshops, interviews and questionnaires to identify and quantify the health impacts and wider outcomes. Outcomes were then valued using proxy financial values to present the overall estimated social value of the self-sampling service.

FINDINGS

Based on a small sample, results indicate that for every £1 spent on the self-sampling service in the prison, a potential value of £4.14 was created. This resulted in a ratio of £4.14:£1. Approximately one-third of the value created (£1,517.95) was categorised as monetarily returnable, whereas the remaining value (£3,260.40) was purely illustrative social value, for example improved mental well-being.

ORIGINALITY/VALUE

This unique pilot study demonstrates the health impacts and wider social value of providing a self-sampling sexual health service to prisoners within an open prison setting. By innovatively testing the feasibility of using a Health Impact Assessment process alongside Social Return on Investment analyses, this paper has outlined how the frameworks can be used in synergy to illustrate not just direct return on investment but also the social value of providing such a service.

The Social Value of Implementing the Ten Steps to Successful Breastfeeding in an Indonesian Hospital: A Case Study

Background: Despite the known importance of breastfeeding for women's and children's health, global exclusive prevalence among infants under 6 months old is estimated at only 41%. In 2018, Indonesia had a lower exclusive breastfeeding rate of 37% at 6 months postpartum; ranging from 20% to 56%, showing unequal breastfeeding support throughout the country. The World Health Organization (WHO) launched the Ten Steps to Successful Breastfeeding (Ten Steps) in 1989, later embedded in UNICEF's Baby-Friendly Hospital Initiative (BFHI) program in 1991. The BFHI aims to encourage maternity facilities worldwide to ensure adequate education and support for breastfeeding mothers by adhering to the Ten Steps and complying with the International Code of Marketing of Breastmilk Substitutes. An Indonesian survey in 2011 found that less than one in 10 government hospitals implemented the Ten Steps. It has been common for Indonesian health services to collaborate with infant formula companies. While no Indonesian hospitals are currently BFHI-accredited, the WHO/UNICEF Ten Steps (updated in 2018) have been adopted in Indonesia's national regulation of maternity facilities since 2012. Internationally, implementation of the Ten Steps individually and as a package has been associated with benefits to breastfeeding rates and maternal and infant health. However, to date, few studies have examined the impact of implementing the Ten Steps in economic terms. This study aims to measure the economic benefit of Ten Steps implementation in an Indonesian hospital. Methods: The study was conducted in January 2020 in Airlangga University Hospital, Surabaya, Indonesia, which has implemented the Ten Steps since it was established in 2012. To understand and generate evidence on the social value of the Ten Steps, we conducted a "Social Return on Investment (SROI)" study of implementing the Ten Steps in this maternity facility. To estimate the costs relating to the Ten Steps we interviewed the financial and nursing managers, a senior pediatrician, and senior midwife due to their detailed understanding of the implementation of the Ten Steps in the hospital. The interview was guided by a questionnaire which we developed based on the 2018 WHO/UNICEF Ten Steps to Successful Breastfeeding. The analysis was supported with peer-reviewed literature on the benefits of Ten Steps breastfeeding outcomes. Results: The total per annum value of investment (cost) required to implement Ten Steps in Airlangga University Hospital was US$ 972,303. The estimate yearly benefit was US$ 22,642,661. The social return on the investment in implementing Ten Steps in this facility was calculated to be US$ 49 (sensitivity analysis: US$ 18-65). Thus, for every US$ 1 invested in Ten Steps implementation by Airlangga Hospital could be expected to generate approximately US$ 49 of benefit. Conclusions: Investment in the Ten Steps implementation in this Surabaya maternity facility produced a social value 49 times greater than the cost of investment. This provides novel evidence of breastfeeding as a public health tool, demonstrating the value of the investment, in terms of social impact for mothers, babies, families, communities, and countries. Breastfeeding has the potential to help address inequity throughout the lifetime by providing the equal best start to all infants regardless of their background. Indonesia's initial moves towards implementing the WHO/UNICEF Ten Steps can be strengthened by integrating all elements into the national regulation and health care system.

Exploring the Impact of Digital Peer Support Services on Meeting Unmet Needs Within an Employee Assistance Program: Retrospective Cohort Study

BACKGROUND

The World Health Organization estimates that 1 in 4 people worldwide will experience a mental disorder in their lifetime, highlighting the need for accessible support.

OBJECTIVE

This study evaluates the integration of digital peer support (DPS) into an employee assistance program (EAP), testing 3 hypotheses: (1) DPS may be associated with changes in EAP counseling utilization within a 5-session model; (2) DPS users experience reduced sadness, loneliness, and stress; and (3) DPS integration generates a positive social return on investment (SROI).

METHODS

The study analyzed EAP utilization within a 5-session model using pre-post analysis, sentiment changes during DPS chats via natural language processing models, and SROI outcomes.

RESULTS

Among 587 DPS chats, 432 (73.6%) occurred after business hours, emphasizing the importance of 24/7 availability. A matched cohort analysis (n=72) showed that DPS reduced therapy sessions by 2.07 per participant (P<.001; Cohen d=1.77). Users' messages were evaluated for sentiments of sadness, loneliness, and stress on a 1-10 scale. Significant reductions were observed: loneliness decreased by 55.04% (6.91 to 3.11), sadness by 57.5% (6.84 to 2.91), and stress by 56.57% (6.78 to 2.95). SROI analysis demonstrated value-to-investment ratios of US $1.66 (loneliness), US $2.50 (stress), and US $2.58 (sadness) per dollar invested.

CONCLUSIONS

Integrating DPS into EAPs provides significant benefits, including increased access, improved emotional outcomes, and a high SROI, reinforcing its value within emotional health support ecosystems.

On NFPs with high social impact that avoid concentrating on a few activities

Background: An influential piece of literature on effective altruism insists that not-for-profit organizations (NFPs) should concentrate their investments on a few activities to maximize their social return on investment (SROI) ratio. However, this creates greater risk for an NFP than building a portfolio of investments in activities. This study investigates whether it is desirable for executives and contributors of NFPs to build a portfolio rather than maximize the expected SROI ratio, and if so, how to build one. Solving these questions will help the chief financial officers (CFOs) of NFPs, who serve as their agents, fulfill their obligations to contributors, who are their principals, and will help advisors provide better services for their contributors, their clients. Methods: Data were collected from a ranking of NFPs, then non-parametric tests were performed on this ranking and the Herfindahl-Hirschman Index (HHI). Results: The HHI are between 2013 and 2688. The results of non-parametric tests do not deny that rank and HHI are independent of each other. Most of the NFPs' investments in activities were in accord with their core competencies. Conclusions: It was found that successful executives build portfolios. The findings of this study should be sufficiently practical in helping NFP executives and contributors decide whether to build portfolios, and if so, how.

Advancing the social return on investment framework to capture the social value of public health interventions: semistructured interviews and a review of scoping reviews

OBJECTIVES

Investment in public health has far-reaching impacts, not only on physical health but also on communities, economies and the environment. There is increasing demand to account for the wider impact of public health and the social value that can be created, which can be captured through the use of the social return on investment (SROI) framework. This study aims to explore the application of SROI and identify areas of advancement for its use in public health.

STUDY DESIGN AND METHODS

Publically available SROI studies of public health interventions previously identified through published systematic scoping reviews were examined through a methodological lens. This was complemented by semistructured interviews with key public health academic experts with experience in the field of SROI. The results were thematically analysed and triangulated.

RESULTS

In total, 53 studies and nine interviews were included in the analysis. All interviewees agreed that SROI is a suitable framework to demonstrate the social value of public health interventions. Developmental aspects were also identified through the analysis. This included a more systematic use of SROI principles and methodological developments. Lastly, it was identified that further advancements were needed to promote awareness of SROI and how it can be used to generate investment.

CONCLUSION

By identifying key areas for advancement, the results from this study can be used to further refine the SROI framework for use within the speciality to promote investment in services and interventions that demonstrate maximum value to people, communities, economies and the environment.

Lessons Learned and Call for Action From Building an International Consensus on Social Return on Investment Modeling of Physical Activity and Sport

BACKGROUND

The Social Return on Investment (SROI) model has been applied to physical activity and sports (PAS) inconsistently in the past. In order to demonstrate that PAS creates social value for society, consistent, scientific-based tools must be developed.

METHODS

In 2022, a group of interdisciplinary researchers started a project to standardize the application of SROI to global PAS activities. A Delphi study, informed by a systematic review on this topic, was used and the present commentary exposes the main conclusions.

RESULTS

Six main lessons can be drawn from the process of building a global SROI applied to PAS: the methodology to measure the impact of PAS at the population level is different from the methodology applied to specific interventions; there is consensus on the impact in health; there is knowledge, but also unanswered questions on the impact of PAS in education; the impact of PAS in population well-being as a promising area; the of impact on crime and social capital requires more research; and there is controversy in the relationship between PAS, and environment, and climate change.

CONCLUSIONS

A global SROI applied to PAS is a powerful tool to demonstrate how an active population can bring value to society. For this purpose, researchers and policymakers are called to action to fill in the gaps that remain open in order to build a robust model.

Assessing the Social and Environmental Impact of Healthcare Technologies: Towards an Extended Social Return on Investment

Stroke is the third leading cause of death and disability overall worldwide. Upper limb impairment is a common consequence for stroke survivors, having negative impact on their quality of life. Robotic rehabilitation, through repetitive and monitored movements, can improve their status. Developed by a team of researchers at Politecnico di Milano, AGREE is an exoskeleton for upper limb rehabilitation at the stage gate between translational research and clinical validation. Since the cost of this device is particularly high, the present study aimed to provide a framework for assessing its value. The Social Return on Investment (SROI) method, able to grasp the economic, social and environmental impact of an activity, was applied, using expert opinions of a pool of clinical engineers and healthcare professionals from different Italian hospitals to obtain information. Environmental impacts were estimated through Life Cycle Assessment in terms of CO₂ emissions and incorporated in the analysis. Considering a 5-year period, the SROI for a single exoskeleton was 3.75:1, and the SROI for the number of exoskeletons projected to be sold was 2.868:1, thus resulting largely in value for money. This study provides a model for combining economic, social and environmental outcomes that, besides contributing to theory, could be useful for decision-making.