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

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 still persists regarding how to successfully operationalize such initiatives, particularly in fragile and conflict-affected settings, and, what the full impacts of such initiatives are. This is a study of Maridi Health Sciences Institute (MHSI) in the Republic of South Sudan (SS), where pre-service training of health workforce was started and how it has evolved over time. The aim of the study was to understand the long-term value that the pre-service training has created in the health system of the country, including its social return on investment (SROI). Methods: In this study, researchers utilized SROI analysis to evaluate the social impact and value of the pre-service training at MHSI in the SS. Data was collected through desk and literature reviews, conducting 15 focus group discussions (FGDs) and 41 key informant interviews (KIIs) with key stakeholders such as MHSI graduates, community members from five counties of Juba, Maridi, Yambio, Bor, and Tonj, and government officials. Quantitative data was collected from 596 respondents composed of the graduates, community members and program staff. Two methods were used to identify the value of outcomes experienced by stakeholders: cost-based valuation from literature and stakeholder revealed preferences valuation. Outcomes were monetized and used to calculate the SROI ratio. Validation sessions were conducted with stakeholders. Results: Key stakeholders impacted by MHSI included graduates, community members in the catchment areas where MHSI graduates are employed, government (national and local), employers, among others. Stakeholders identified several outcomes they experienced. Graduates identified increased professionalism and skills as the most valuable outcome they experienced. Community members reported improved access to care as the most valuable outcome they experienced from their perspectives. Most outcomes experienced across all stakeholder groups lasted for more than 5 years. The SROI ratio was 1:11, which means that for every $1 invested at MHSI, approximately $11 was created in social value. Conclusions: MHSI became known as a model of excellence in the country. It created numerous benefits for various key stakeholders, including graduates, community members, local and national government, employers, and more. Findings demonstrate the success of MHSI and inform opportunities to increase its impact. Implications may be relevant for training interventions in similar contexts.