Return on Investment for Emergency Obstetric Care Training

Return on Investment for Emergency Obstetric Care Training Social Return on Investment for Emergency Obstetric Care Training in Kenya Dedication â€Å"To philanthropy and all those contributing to making the world a better place† List of tables Table 1‑1: Summary table of social impact assessment methods Table 2‑1: WHO emergency obstetric care signal functions.. Table 3‑1: Krlev et al. 12-point quality assessment framework Table 3‑2: Sources of retrieved SROI studies. Table 3‑3: Criterion quality scores of health SROI studies across the 5 dimensions Table 3‑4: Health interventions that have been measured with SROI Table 3‑5: Summary table describing application of the SROI methodology in Health Table 3‑6: Summary of duration of health SROI analysis. Table 4‑1: Outputs of the current phase of the Making it Happen programme Table 4‑2: Content of the LSS-EOC NC. Table 4‑3: Distribution of Kenyan population across age groups. Table 4‑4: Kenyan Key development indicators.. Table 4‑5: EmONC indicators in Kenya compared to UN standards. Table 5‑1: Description of SROI principles. Table 5‑2: MiH outcome and output data indicators relevant for SROI analysis Table 6‑1: Stakeholder analysis of the EmONC training component of the Making it Happen programme Table 6‑2: Primary and secondary data required from the included stakeholders List of figures Figure 1‑1: Types of Social Return on Investment Studies Figure 2‑1: Annotation of the logic model (version 1). Figure 2‑2: Annotation of the logic model (version 2). Figure 2‑3: DFID 3Es + CE framework for Value for Money.. Figure 3‑1: Schematic representation of the conceptual framework underpinning the review Figure 3‑2: PRISMA flow diagram summarising the search process. Figure 3‑3: Mean quality scores of health SROI studies since 2005. Figure 3‑4: Number of public health SROI articles published since 2005. Figure 3‑5: Number of health SROI studies published by year, showing countries where the methodology was applied Figure 3‑6: Distribution of countries conducting SROI studies Figure 4‑1: Map of Kenya showing the eight provinces and the surrounding countries Figure 5‑1: SROI process map Figure 5‑2: Methods to be used within the SROI data collection stages.. Figure 6‑1: Analysis of stakeholders related to EmONC training in Kenya List of appendices Appendix 1: Search strategy Appendix 2: Systematic review results Appendix 3: Ethics Appendix 4: Materials relating to Making it Happen Appendix 5: Questionnaires Abbreviations ACAFIAtkisson Compass Assessment for Investors AIDSAcquired Immune Deficiency Syndrome BACOBest Available Charitable Option BEmOCBasic Emergency Obstetric Care BEmONCBasic Emergency Obstetric and Newborn Care BoP Base of Pyramid BScBalanced Scorecard BVABlended Value Accounting CAQDAS CEmOCComprehensive Emergency Obstetric Care CEmONCComprehensive Emergency Obstetric and Newborn Care CBACost Benefit Analysis CEACost-Effectiveness Analysis CMA Cost-Minimization Analysis CMNHCentre for Maternal Newborn Health CRTCluster Randomised Trials CSOCivil Society Organisation CUACost-Utility Analysis DALYs Disability-Adjusted Life Years DFIDDepartment for International Development DHDepartment of Health DHS Demographic and Health Survey EEEconomic Evaluation EmOC Emergency Obstetric Care EmONCEmergency Obstetric and Newborn Care EOC NCEssential Obstetric Care and Newborn Care FGFocus Group FGDFocus Group Discussion GRIGlobal Reporting Initiative HCPHealth Care Providers HEFCEHigher Education Funding Council for England ICPIntegrated Care and Prevention IDIIn-Depth Interview KHSSIP Kenya Health Sector Strategic and Investment Plan KIIKey Informant Interview KPIKey Person Interview LADSILabour and Delivery Satisfaction Index LATHLiverpool Associates in Tropical Health LEMLocal Economic Multiplier LMICsLow and Middle Income Countries LSS-EOCNCLife Saving Skills – Essential Obstetric Care and Newborn Care LSTMLiverpool School of Tropical Medicine MARPMost At Risk Population MDG-ScanMillennium Development Goal Scan MICSMultiple Indicator Cluster Survey MIFMeasuring Impact Framework MiHMaking It Happen MMRMaternal Mortality Ratio MNHMaternal and Newborn Health MOHMinistry of Health MOMSMinistry of Medical Services MOPHSMinistry of Public Health and Sanitation MSCMost Significant Change nefNew Economics Foundation NGOsNon-Governmental Organisations OASISOn-going assessment of Social Impacts OVCOrphan and Vulnerable Children PLHIVPeople Living with Human Immuno-deficiency Virus PLHWAPeople Living With AIDS PSIAPoverty and Social Impact Analysis PTOPerson Trade-Off QALYsQuality-Adjusted Life Years QIQuality Improvement RCOGRoyal College of Obstetricians and Gynaecologists RCTRandomised Controlled Trials REDFRoberts Enterprise Development Fund RFRoberts Foundation ROIReturn on Investment SAASocial Accounting and Auditing SBASkilled Birth Attendant SCStakeholder Consultation SCBASocial Costs-Benefits Analysis SDRSocial Discount Rate SIASocial Impact Assessment SIAASocial Impact Analysts Association SRASocial Return Assessment SRHSexual and Reproductive Health SROISocial Return on Investment SSQSix Simple Questions STDsSexually Transmitted Infections SVAStakeholder Value Added TBLTriple Bottom Line ToCTheory of Change TSOThird Sector Organisation UKUnited Kingdom UNUnited Nations UNICEFUnited Nations Children’ Fund VfMValue for Money WBWorld Bank WHOWorld Health Organization 1 Introduction 1.1 Purpose of the chapter This chapter introduces the social return on investment methodology – its definition, history as well as strengths and weaknesses of its application. It then proceeds to identify examples of previous applications of the method, explores any previous intersection of the methodology with the maternal and newborn health field and provides the rationale for the study. Finally, the objectives of this research and an overview of the thesis are provided. 1.2 What is Social Return on Investment? The first definition of Social Return on Investment (SROI) is â€Å"a simple financial assessment of socio-economic value. SROI compares a project’s net benefits to the investment required to generate those benefits over a certain period of time† (Emerson and Cabaj, 2000). Over time, this definition has been modified. In the most recent SROI methodology guidance, SROI is defined as â€Å"a framework for measuring and accounting for the much broader concept of value. It seeks to reduce inequality and environmental degradation and improve wellbeing by incorporating social, environmental and economic costs and benefits† (Nicholls et al., 2012). This definition is most commonly referred to in the literature, when authors define SROI, probably because it is stated within the SROI guidance. New Economics Foundation (nef) also defines SROI as â€Å"an analytic tool for measuring and accounting for a much broader concept of value, taking into account social, economic and environmental factors† (nef, 2014). SROI measures change from the perspective of stakeholders that experience or contribute to a particular activity, intervention, project, programme or policy. â€Å"It tells the story of how change is being created by measuring social, environmental and economic outcomes and uses monetary values to represent them† (Nicholls et al., 2012). Data collection and subsequent analyses allow calculation of a benefits-to-costs ratio. For example, a ratio of 4:1 indicates that an investment of  £1 delivers  £4 of social value. There are two types of SROI (Nicholls et al., 2012) [Figure 1-1]: Evaluative SROI: This retrospectively measures outcomes that have already happened. Forecast SROI: This estimates how much social impact will be generated if the activities to be conducted meet their intended outcomes. Figure 1.1: Types of Social Return on Investment Studies 1.3 History of SROI A review of the development of the SROI methodology would aid understanding of the initial considerations of those who developed the tool and the capabilities and potentials of the tool. This understanding is critical for this research as it provides a foundation upon which the application of the SROI framework in the maternal and newborn health (MNH) area can be better understood. Roberts Foundation (RF) developed the initial SROI framework in 1996, presented in a report titled New Social Entrepreneurs: The Success, Challenge and Lessons of Non-profit Enterprise Creation (REDF, 1996). The purpose of the first SROI report by REDF was to demonstrate the blend of financial, social and environmental value that all the social enterprises within REDF’s funding portfolio were producing compared to the total investment the organisation was making. This first SROI did not attempt to account for all benefits accrued from a programme, but estimated the cost savings or revenue contributions that are attributed to the programme. The framework utilised a modified discounted cash flow analysis for this calculation to demonstrate impact (Emerson and Cabaj, 2000; Emerson et al., 2000). In 1997, the RF, under its new initiative Roberts Foundation Enterprise Development Fund (REDF) updated the framework so to have the capacity to account for total organisational social return on investment and adjusted to be able to account for actual performance that could be continuously updated. REDF recognised more limitations in the methodology (Emerson et al., 2000), but has since not produced any further SROI reports or guidelines. However, the concepts that underpinned the development of this initial framework have been built upon in the subsequent development of the methodology over the past two decades (Tuan, 2008). Guidelines for SROI application have been produced in year 2000 (Emerson and Cabaj, 2000), 2004 (Lingane and Olsen, 2004) and 2006 (Scholten et al., 2006). In 2008, the United Kingdom (UK) Office of the Third Sector (Now referred to as Office for Civil Society (Civil Society Media, 2010)), which is responsible for charities, social enterprises and voluntary org anisations in the Cabinet Office (UK Government, 2014) launched the Measuring Social Value project (Arvidson et al., 2010) and this led to the development of an updated guideline in 2009 (Nicholls et al., 2009) and the production of another revision three years later (Nicholls et al., 2012). These revisions have over the years integrated the initial REDF SROI methodology, which was essentially a social impact measurement tool with principles and processes normally used in economic evaluations and financial return on investment to build a framework that captures social, economic and environmental impacts of interventions (Rotheroe and Richards, 2007). This concept of capturing the broader impacts is widely referred to as the â€Å"triple bottom line† (Norman and MacDonald, 2004), which is in itself encapsulated within the â€Å"blended value accounting† theory (Emerson, 2003). Furthermore, through this evolution, a more detailed stakeholder analysis is now included, shorter time frames are used for estimations and a process to adjusts the results for outcomes that may be attributable to different organisations has been incorporated into the calculation of the SROI ratio (Tuan, 2008). Discussions on how best to structure the methodology are on-going and networks such as the European SROI Network (ESROIN), formed in 2004, the SROI Network (international), formed in 2008 and subsequently affiliated networks formed in Sweden, Canada and Australia, are constantly leading and shaping this process (SROIN, 2014a). The methodology is gradually gaining interest in Africa and Asia too. The drive to develop the methodology has come from within and without the third sector, as third sector organisations (TSOs), such as not for profit organisations, charities and voluntary organisations, are increasingly getting involved in delivering public services and are viewed as development partners who need to show ‘value for money’ (Netten et al., 2010). On one hand, TSOs are pushing to become better in being accountable and demonstrating the value of their activities to donors. On the other hand, the focus of funding organisations has shifted from â€Å"output† to â€Å"outcome† and â€Å"impact† and from â€Å"generous giving† to â€Å"accountable giving†, through which they can demonstrate that evidence-based decisions have informed their choice of funded interventions, projects or programmes (Leat, 2006). 1.4 Application of the SROI methodology The application of the SROI framework can vary from measurement of the impact and social value generated by a project to a programme or indeed to an entire organisation (Millar and Hall, 2013). A rapid search of academic databases does not retrieve substantial amounts of research work that have used the SROI methodology, however the methodology is very popular within the third sector and has been widely embraced by the Office of the Civil Society, donors, commissioners and the public sector (Ainsworth, 2010; Heady, 2010). Its wider practice-based use but limited application within academia restricts its development and could potentially be the reason for its minimal uptake (Arvidson et al., 2010; Ebrahim and Rangan, 2010). Since its first use by REDF in 1996 (Emerson and Cabaj, 2000), the SROI methodology has been broadly applied to many organisations and within many industries. Examples of its use across different sectors include agriculture, where it was used to account for impact of care farming (Leck, 2013); environmental, where it was used to account for impact of a natural regeneration project (Weston and Hong, 2012); energy, where it was used to account for impact of energy efficiency of homes in Germany (Kuckshinrichs et al., 2010); social, where it was used to account for impact of providing training and employment for blind people (Sital-Singh, 2011), transport, where it was used to account for impact of a co-ordinated shared transport service which provides access to workplace, training and childcare in rural Scotland, where no alternative transport is available. (Wright et al., 2009) and indeed health, where amongst other examples, has been used to account for impact of a community-based pa ediatric asthma programme and provision of highly nutritious breakfast for school children in Sydney, Australia (Bhaumik et al., 2013; Varua and Stenberg, 2009). As regards its application in health [described in detail in Chapter 2: systematic review of SROI application in health], It is worth noting that in 2009, the UK Department of Health (DoH), with the support of the Cabinet Office, commissioned an action research project on which five health focused social enterprises were supported to conduct SROI analysis (Department of Health, 2010). This research demonstrated the relevance of the SROI methodology to the health sector and proved that there were additional benefits of using the methodology (Millar and Hall, 2013). However, to the best of our knowledge, though relevant and appropriate, there is no reported evidence of the application of the SROI methodology in the field of maternal and newborn health. 1.5 Difference between SROI and other related methodologies As mentioned above, the SROI methodology has evolved from a combination of social impact assessment tools and economic evaluation tools. It is therefore important to understand how SROI differs from these existing tools and identify what innovative approach it actually offers. When compared to other social impact measurement tools, there are subtle differences. There are several tools that have been previously or are currently being used in measuring and accounting for social impact (Acumen Fund, 2007; Brest and Harvey, 2008; Brest et al., 2009; Centre for High Impact Philanthropy, 2008; Clark et al., 2004; Emerson et al., 2000; Maas and Liket, 2011; Maas, 2008; Maughan, 2012; Nicholls et al., 2012; Owen and Swift, 2001; Schaltegger et al., 2004). Table 1‑1: Summary table of social impact assessment methods Method Primary application to Date Process Outcome Impact Monetisation Non Profit For Profit Government Acumen Scorecard à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Atkinsson Compass Assessment for Investors (ACAFI) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Balanced Scorecard (BSc) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Benefit-Cost Analysis à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Best Available Charitable Option (BACO) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Base of Pyramid (BoP) Impact Assessment Framework à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Cost per Impact à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Expected Return à ¯Ã¢â‚¬Å¡Ã… ¸ Global Reporting Initiative à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Local Economic Multiplier (LEM) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Measuring Impact Framework (MIF) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Millennium Development Goal Scan (MDG-Scan) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Most Significant Change à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Ongoing Assessment of Social Impact (OASIS) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Poverty and Social Impact Analysis à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Social Accounting and Auditing (SAA) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Social Costs-Benefits Analysis (SCBA) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Social Return Assessment (SRA) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Social Return on Investment (SROI) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Stakeholder Value Added (SVA) à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ Theories of Change à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ à ¯Ã¢â‚¬Å¡Ã… ¸ [Table 1-1] shows the key characteristics of these different social impact measurement tools described in the literature, identifying the tools that monitor efficiency and effectiveness of outputs, indicators or variables (process); tools that relate outputs and outcomes and to substantiate incremental outcomes above what would have occurred if the intervention was not implemented (impact) and tools that monetize outcomes and/or impact by transforming them to monetary value (monetization). Finally the table details the sector(s) in which the method has thus far been applied – non-profit (third sector), for profit (commercial) or public sector (government). Of these tools, SROI appears to have gained wide acclaim because of its involvement of all stakeholders, who independently define the value they have experienced because of the intervention. In addition, SROI monetises costs and benefits and also ticks all the boxes of the logical framework, as it accounts for processes, outcomes and impact (Arvidson et al., 2010; Nicholls et al., 2012). The other similar methodologies to SROI are Economic Evaluation (EE) tools. These compare two or more alternative interventions in terms of their costs and benefits (Drummond et al., 1997). Economists have distinguished four types of economic evaluation: Cost-minimization analysis (CMA), Cost-effectiveness analysis (CEA), Cost benefit analysis (CBA) and Cost-utility analysis (CUA). While the definition of cost remains the same, the manner of accounting for the benefits differs across the types (Drummond et al., 2005). These different types of EE are described below: Cost-minimization analysis (CMA): In which, there is proven evidence that equivalent effectiveness of the comparators in question. Thus the more cost-effective option would be the cheaper one (since both options have similar outcome). Cost-effectiveness analysis (CEA): Effectiveness is measured in ‘natural units’ such as life years gained. Cost benefit analysis (CBA): Costs and benefits are monetised, with the cost-effective option being the one that results in a lower monetised ratio. Cost-utility analysis (CUA): Outcome is measured in Quality-adjusted life years (QALYs) or Disability-adjusted life years (DALYs), which is a composite metric of both length and quality of life. When compared to the SROI methodology, whereas a large focus of economic evaluation tools is on the microeconomic evaluation of the impact of any intervention, SROI accounts for not just economic value, but social and environmental impacts. It has been described as an extension of the cost-benefit analysis that incorporates broader socio-economic outcomes (Westall, 2011). In addition, SROI focuses on stakeholders, uses financial proxies, is more of a management tool, is more likely conducted by organisations themselves, while CBAs are usually conducted by external agents and the most up to date guidance does not recommend comparing estimated SROI ratios, unlike CBAs that are designed to be comparable. However, these differences appear to be largely based on â€Å"the style of each approach, rather than the true substance† (Arvidson et al., 2010). 1.6 Strengths and limitations of the SROI methodology 1.6.1 Strengths of the SROI methodology Practitioners and previous authors have identified some of the key strengths of the SROI methodology. Firstly, the fact that the SROI process generates a singular ratio that captures the broader impact (positive and negative) of an intervention is perceived as a key strength (Millar and Hall, 2013). One other strength is its meaningful engagement of stakeholders and its representation of their benefits in ways that are unique to the stakeholders themselves (Millar and Hall, 2013). More so, the fact that this benefits experience or impact experience is being explained from the perspective of the stakeholder is a unique characteristic of SROI, and this important stakeholder view is often neglected in conventional impact evaluation tools (Rauscher et al., 2012). In addition, the method provides a platform for social enterprises to leverage and/or effectively communicate their impact. This ultimately promotes better communication amongst all partners, whether they are beneficiaries, funders or implementers (Mdee et al., 2008). The SROI process also strengthens accountability and transparency systems of social enterprises (Arvidson et al., 2010). Finally, the SROI process is a very useful auditing tool to aid management decisions and service improvement (Social Ventures Australia (SVA) Consulting, 2012). 1.6.2 Limitations of the SROI methodology However, there are limitations of the methodology, just as there are of other impact evaluation methodologies (Arvidson et al., 2010). Some methodological limitations that have been raised include the difficulty of attaching financial values to â€Å"soft outcomes† that require subjective evaluation to generate â€Å"financial proxies† (Lingane and Olsen, 2004) such as self-esteem or confidence (Bertotti et al., 2011). Albeit still in developmental stage, is the Wiki Values, Outcomes and Indicators for Stakeholders (VOIS) database of the SROI Network is an attempt are to standardise such outcomes by recommending indicators and values of such outcomes that can be used to account for them (Rauscher et al., 2012). An example of a health related outcome on WikiVOIS is â€Å"change in incidence of abortion†. Contributors to the database have suggested that â€Å"cost of medical termination of pregnancy† can be used to value this outcome in Canada (The Global Value Exchange, 2013). In addition, the methodology needs an estimation of â€Å"what would have happened anyway† to calculate the value that can be attributed to the specific organisation, programme or intervention, however, this counterfactual data is seldom available (Cordery, 2013; Heady, 2010). Furthermore, the lack of comparability of SROI ratios across different organisations and/or interventions is perceived as a limitation (Ryan and Lyne, 2008). On practical grounds, SROI methodology is adjudged to be cost-intensive and requires the expertise and know-how of professionals and in some cases training, some of which small organisations cannot afford (Wood and Leighton, 2010). 1.7 Rationale for the study Though applicable and relevant, to the best of our knowledge, there is no documented application of the SROI methodology in the area of maternal and newborn health. For most MNH interventions, the key beneficiaries are the women and their families. There is currently no tool that captures the perspectives of all these stakeholders on impact of any intervention in one summary figure. This underscores the need to explore the use of primary data that will include inputs of those benefiting from MNH interventions, as this may potentially be useful in identifying the most complete estimate of the impact of these interventions. To buttress this, some authors have pointed out that this complete evaluation of MNH interventions needs to include identification of the most culturally appropriate intervention for each local setting and peculiar issues unique to the setting. Those who are the major beneficiaries of the intervention are better positioned to identify these culturally appropriate in terventions. Thus the call for culturally sensitive impact evaluations, which attempt to identify specific causes of problems, rather than basing decisions on â€Å"superficial† indicators such as maternal mortality rate, which is only quantitative and does not capture softer outcomes that also demonstrate impact of an intervention (McPake and Koblinsky, 2009; Pradhan, 2008). Secondly, data used as maternal health indicators are usually generated from relatively credible sources such as the Demographics and Health Survey (DHS), Multiple Indicator Cluster Survey (MICS) and World Development Indicators, but the problem of lack of uniformity in the process by which the indicators were generated remains (Pradhan, 2008). This is complicated by the fact that a large number of developing countries, that receive aid, do not have accurate or complete secondary data to base impact evaluation on (WHO,

Mne Challenges in Emerging Markets Essay

International business and global innovation Individual report 1. Please discuss MNEs challenges in emerging markets? How can MNEs solve these? First of all, I would like to mention that It would be hard to describe challenges in emerging markets of the whole world, because question either can be roughly generalized or otherwise requires deep and wide research which is not the case right now. That’s why in my discussion I would like to stop on one country – Russia. The Russian economy is growing by 7. 7 per cent per year, supported by the soaring price of oil. But with stories about government corruption and mobsters, how attractive is the country for the more entrepreneurial-sized business? I would like to discuss some of the challenges most companies face while entering this emerging market. I would like not to talk in details about common problems and stereotypes which are often mentioned about Russia, amongst those I already noticed are high level of corruption, gangsters and seemed political instability. And one thing I would like to mention first is a labor problem. Management in Russia is faced presently with two major issues in the labor force: the battle for highly qualified specialists and the cost-to-productivity ratio. The battle for top specialists has become extremely rough in the recent time. Recruiting companies are very busy these days with headhunting. Professionals already receiving top salaries at multinational corporations are being stolen away, often by Russian majors, attracted by dramatic salary increases. It used to be that the professional would look at these offers with skepticism, questioning the reputation or stability of most Russian companies. Nowadays, these people do not worry as much and instead look at the cost-of-living, which is also rising dramatically, especially in major cities among which are Moscow, Saint Petersburg, Yekaterinburg and many others. The situation has gotten so bad that many companies are afraid to let their specialists be quoted in articles or to send them to conferences or other events where headhunters or competitors may be looking around in search for their next pray. It would be impossible for me not to notice the other side of this process which is the fact that labor market has become â€Å"spoiled.Salaries are steadily increasing but productivity levels are not. At the current salary levels, business owners and management are becoming increasingly sensitive to productivity levels and attempting to demand more work ethic and more productivity from their highly paid employees. At the same time, there is very little choice in the current market. More and more foreign-owned companies in partic ular seem to be looking more closely at hiring and importing foreigners, now that Russian salaries are roughly on par with those of foreigners in many sectors. Foreigners coming from countries known for higher productivity levels and initiative are especially attractive – minimally in the hopes that they can set an example. Young foreigners eager to gain experience in Russia’s developing market, are finding work – particularly in sales, client relations, business development, and marketing. So, generally it can be summed up that finding qualified local partners and employees is a difficult process. The pool of managers who understand Western accounting and business practices remains limited, as well as the pool of qualified, experienced Russians proficient in English. Another big challenge and â€Å"nightmare† for most foreign-owned companies operating in Russia is lease rates for commercial real-estate. It’s avoided by most foreign-operated Class A properties, but the situation is quiet bad in most of it’s sector lower. It is the rare landlord who fulfills most of his side of the contract. Moreover, rental contracts in Russia are usually biased toward the landlord. As a result foreign companies often find themselves looking for a new place. However, finding a better situation can be extremely difficult in Russia’s current real estate market. Centrally located, Class A property can run $USD 2000 and more per square meter per year. Bidding wars are not unusual and most other classes of property are seeing equal pressure. These are two challenges which I would like to point out, apart from that I’d like to briefly mention other challenges: * Government bureaucracy, poorly established rule of law and corruption affect such areas as establishing a business, tax collection, dispute settlement, property rights, product certification and standards, as well as Russian Customs clearance.Adequate financial resources for Russian buyers still remain a problem, but it is not as acute as it was in years past. There are more foreign banks operating in Russia and more cash circulating within the economy due to the Russian oil and gas boom. * The Russian government continues to use its oil and gas resources to increase the states’ ownership in certain strategic industries and companies. So it is not completely clear to forei gn companies which sectors are open to them for investment without Russian majority partners. The Russian Government continues its work on defining what are Russia’s strategic sectors. And after I stated challenges I must answer the second part of the question which is how to overcome these challenges. And in my view, a fundamental consideration must be there as a major phase of preparation if someone is going to go into Russia. This preparation involves surrounding company’s branch with reliable people, having an adequate concept of what is to be done and a well-defined strategy plan. You also need the necessary investment capacity and time arranged to follow this way. 2. You are expatriated to work in an emerging market (e.India or Brazil) What capabilities do you need? What and how can firm provide you for the expatriation in emerging markets? (Maybe take one country as example) I think generally company must have an on-going business processes with the country, otherwise the necessity of having employees overseas is indistinct. There can be several cases when headquarters would need their employee to be expatriated to the subsidiary or partner company, f or example:* Company knowledge and experience diffusion or sharing; * Leader position in one of the overseas branches;Emerging market opportunities opened etc. Brazil is a great example of an emerging market. And if life will propose the opportunity for me to work there, I think I’d take it with great pleasure. Of course, there’re certain capabilities I must possess to take this kind of job opportunity: * Particularity of doing business in Brazil is that a potential Brazilian partner is essentially looking for two things: someone they like and trust as well as someone who is competent in business. The most important of these is to build a strong relationship first which will then naturally lead to trust. Time must be invested in getting to know people on a personal level in order to allow for open and honest discussions in business. So, naturally, the environment will require from me to be a trustworthy, sophisticated person with a clear understanding of benefits and goals. * Another point Brazilians usually comment on is the tendency of European and American business people to â€Å"get straight down to business†. This can be seen as offensive and even aggressive. It is good practice to indulge in small talk whether it is asking about their children or chatting about the latest news or football (soccer) results. This interesting feature of business ethics will require from me a positive, easygoing attitude at all times. * Despite Brazil poses as an emerging, fast-growing market English proficiency still remains low levels especially in the social sector and in the matter of daily life. So in my understanding extradition to Brazil will be more effective with readiness to learn Portuguese at least until the level which will allow me to be independent on the matter of daily life, e. g. survival level of it. * Apart from all of that, I should have a clear view of business ethics and interpersonal relationship customs in Brazil. One of the important things is that I will have to be ready for a total change of values and concepts in any part of business and social life. In fact, that rule can be applied to all of cultures. In Rome act like a Roman.

Should Marijuana Be Legalized - 1350 Words

One of the most controversial civil arguments in politics in the past decade would have to be the legalization of marijuana. The sale and production of marijuana have been legalized for medicinal uses in over twenty states and has been legalized for recreational uses in seven states. Despite the ongoing support for marijuana, it has yet to be fully legalized in the federal level due to cultural bias against â€Å"pot† smoking and the focus over its negative effects. However, legalizing marijuana has been proven to decrease the rate of incrimination in America, it has stimulated the job market while bringing tax revenue up, and it has been shown to have medicinal benefits to healthy American adults and certain children Critics claim that the legalization of marijuana of a federal level would inevitably cause crime rates to increase due to its psychoactive effects on the brain. Despite popular theory, legalizing marijuana is proven to decrease the rate of incrimination from marijuana possession in the United States. According to the Editorial Board from the New York Times and FBI figures, â€Å"there were 658,000 arrests for the possession of marijuana in 2012† and the majority of these arrests were made on small offence, young minorities who haven’t previously carried a criminal record. According to the Drug Policy Alliance (DPA) and the Colorado Court System, there has been an over eighty percent decrease marijuana possession arrests in Colorado – a state where marijuana has beenShow MoreRelatedShould Marijuana Be Legalized?849 Words   |  4 Pageswhether marijuana should be legalized. Around 23 states have legalized marijuana for medical and recreational use. In the state of Illinois, medicinal use of marijuana has been passed on April 17, 2013. Since January 2014, patients are able to obtain marijuana with a doctor s recommendation. The new debate is whether marijuana should be legalized for the general public as a recreational drug. Although some believe that marijuana is harmless, and that it has beneficial medicinal uses, marijuana should Read MoreShould Marijuana Be Legalized?1715 Words   |  7 PagesMarijuana in Society Cannabis, formally known as marijuana is a drug obtained from the tops, stems and leaves of the hemp plant cannabis. The drug is one of the most commonly used drugs in the world. Only substances like caffeine, nicotine and alcohol are used more (â€Å"Marijuana† 1). In the U. S. where some use it to feel â€Å"high† or get an escape from reality. The drug is referred to in many ways; weed, grass, pot, and or reefer are some common names used to describe the drug (â€Å"Marijuana† 1). Like mostRead MoreShould Marijuana Be Legalized?1489 Words   |  6 Pagescannabis plant or marijuana is intended for use of a psychoactive drug or medicine. It is used for recreational or medical uses. In some religions, marijuana is predominantly used for spiritual purposes. Cannabis is indigenous to central and south Asia. Cannabis has been scientifically proven that you can not die from smoking marijuana. Marijuana should be legalized to help people with medical benefits, econo mic benefits, and criminal benefits. In eight states, marijuana was legalized for recreationalRead MoreShould Marijuana Be Legalized?1245 Words   |  5 PagesMarijuana is a highly debatable topic that is rapidly gaining attention in society today.   Legalizing marijuana can benefit the economy of this nation through the creation of jobs, increased tax revenue, and a decrease in taxpayer money spent on law enforcement.   Ã‚  Many people would outlaw alcohol, cigarettes, fast food, gambling, and tanning beds because of the harmful effects they have on members of a society, but this is the United States of America; the land of the free and we should give peopleRead MoreShould Marijuana Be Legalized?1010 Words   |  5 PagesThe legalization of marijuana became a heated political subject in the last few years. Twenty-one states in America have legalized medical marijuana. Colorado and Washington are the only states where marijuana can be purchased recreationally. Marijuana is the high THC level part of the cannabis plant, which gives users the â€Å"high† feeling. There is ample evidence that supports the argument that marijuana is beneficial. The government should legalize marijuana recreationally for three main reasonsRead MoreShould Marijuana Be Legalized?1231 Words   |  5 Pagesshows the positive benefits of marijuana, it remains illegal under federal law. In recent years, numerous states have defied federal law and legalized marijuana for both recreational and medicinal use. Arizona has legalized marijuana for medical use, but it still remains illegal to use recreationally. This is absurd, as the evidence gathered over the last few decades strongly supports the notion that it is safer than alcohol, a widely available substance. Marijuana being listed as a Schedule I drugRead MoreShould Marijuana Be Legalized? Essay1457 Words   |  6 PagesSHOULD MARIJUANA BE LEGALIZED? Marijuana is a drug that has sparked much controversy over the past decade as to whether or not it should be legalized. People once thought of marijuana as a bad, mind-altering drug which changes a person’s personality which can lead to crime and violence through selling and buying it. In the past, the majority of citizens believed that marijuana is a harmful drug that should be kept off the market and out of the hands of the public. However, a recent study conductedRead MoreShould Marijuana Be Legalized?1596 Words   |  7 Pages But what needs to be known before a user can safely and completely make the decision if trying Marijuana is a good idea? Many do not want the drug to be legalized because they claim that Cannabis is a â€Å"gateway drug†, meaning it will cause people to try harder drugs once their body builds up a resistance to Marijuana, because a stronger drug will be needed to reach a high state. This argument is often falsely related to the medical si de of the debate over legalization. It is claimed that this wouldRead MoreShould Marijuana Be Legalized?985 Words   |  4 PagesLegalize Marijuana Despite what people believe about marijuana, it hasn’t once proved to be the cause of any real issue. It makes you wonder what the reason as to why there is a war on drugs. Why is marijuana the main concern? Since the time that alcohol and tobacco became legal, people wonder why marijuana isn’t legal yet. The fact that marijuana is illegal is mainly caused by the amount of money, jobs, and pride invested in the drug war. Once the government starts anything, they stick to it. AtRead MoreShould Marijuana Be Legalized?1145 Words   |  5 PagesLegalizing Marijuana Marijuana is a drug that has been actively used for centuries. This drug can be traced back to 2737 BC by the Chinese emperor Shen Nung. He spoke about the euphoric effects of Cannabis and even referred to it as the â€Å"Liberator of Sin.† Since early on, marijuana was seen as a medicinal plant that was recommended for medical uses. Marijuana is currently in schedule I, which means that physicians are not allowed to prescribe it in the United States (Hart, Ksir 2013). This drug

Understanding The Impact Of Junk Food Essay - 1510 Words

NAME: SHIVAM DHAR ENROLLMENT NUMBER : H2015BAMA31 BA 1ST YEAR LIFE SCIENCES ASSIGNMENT TOPIC : Understanding the Impact of Junk Food INTRODUCTION Junk Food is that type of food which doesn’t contain nutritional value. It do not contain high level of calories and has little protein, vitamins and minerals. Such foods are also not good for health and has negative effects after consuming them. Why there is a More Demand of Junk Food? There are following reasons which shows that why people are attracted towards junk food:- â ¦  Preparation of junk food doesn’t take so much time and it is easy for consumption also. â ¦  It is also attracted because of the taste which is a mix-up of oils, salts and sugars. â ¦  Addition of food additives and colours which gives us great taste. â ¦  Packaging and advertising are also one of the reasons which attracts people, children and small age children to purchase fast foods. IMPACTS OF JUNK FOOD â ¦  The Fast Food effects on Health :- â ¦  Digestive System – Good digestion is very crucial for maintaining healthy immune function. A healthy digestive system depends on a healthy diet. Fast foods are not good for digestive systems as they slowdown the digestion process making the stomach bloated. If we have to digest food then stomach requires enzymes so that it will help in digesting the food. For digestion, people should eat healthy food because food is absorbed by intestines and it needs fibre and water toShow MoreRelatedThe Obesity Epidemic Of Obesity967 Words   |  4 PagesThe comprehensive assortment of convenient processed foods high in sugar, salt and fat, frequently marketed in large serving sizes with excessive sides, has ultimately made selecting healthy eating choices more difficult for the average consumer and policymakers. Various health experts maintain the onslaught of advertising and promotion surreptitiously and unfavourably influencing ingestion patterns and food partialities of individuals further complicates the issue . There has been substantial encouragementRead MoreImpact Of Advertising On Children, Branding, And Abuse891 Words   |  4 PagesThere are three issues of advertisement impact our society. The issues are impact on children, branding, and abuse. The first issue of advertisement is the impact on children. Because our life is full of advertisements, children are able to see ads more easily than past. Thus, the impact of ads to children is highly concerned by society. One of plenty reasons, which make society highly sensitive, is that children are lack of ability of fully understanding the ads that they are dealing with. (BakerRead MoreResearch Proposal for Fast Food Consumption1143 Words   |  5 PagesUsman 4. Nausherwan Khan Proposed Research Topic: A statistical analysis of fast food consumption and trends in Pakistan. Purposes: In Pakistan, the fast food trend has entered mainstream. It has taken its roots from the American culture of fast food. Many multinational eateries like McDonald, Pizza Hut, KFC, Dunkin Donuts and Hardees have opened many branches all across Pakistan. These US fast food chains have tailored their menu to local tastes. An example of the same is Pizza Hut. BeingRead MoreMass Media And Its Impact On Society1306 Words   |  6 Pagesand more. Mass media influences the society especially the younger generation and shape their opinions and decisions. The study of the impacts of mass media requires a great understanding. Mass media have both negative and positive influences on the younger minds and understanding these influences is one’s social responsibility. Starting up with the positive impact, the greatest advantage of mass media is the awareness and knowledge it is gifting to youth and the rest of the society. In this competitiveRead MoreOverweight and Obesity: the New Endemic Diseases Essay906 Words   |  4 PagesFast food, or junk food as some call it, is becoming more popular than ever; its convenient, predictable and fast. It has become a part of the busy American lifestyle. Eating at McDonalds once every day and spending the rest of the day in a school bench or in front of the computer or television is making todays children fatter and fatter. Overweight is today a bigger problem in the world than starvation. In 1999 13% of the children aged 6 to 11 and 14% of adolescents aged 12 to 19 in the UnitedRead MoreWith Reference to Morgan Spurlocks Supersize Me, Examine and Evaluate How L inguistic, Structural and Presentational Devices Are Used in This Polemic Documentary1573 Words   |  7 PagesMcDonalds food being unhealthy but it still convinces us that McDonalds is trying to be malicious on purpose. In his conclusion he simply restates what made him go on his one month eating binge, which is that McDonalds food cant be proven to have caused the two girls obesity and health problems shows us what happened to him when he ate only McDonalds and gives us statistics and evidence which completely proves his point. So while getting the viewer interested about McDonalds and other food corporationsRead MoreShould Banned Be Banned For Minors? Essay1739 Words   |  7 Pages(Merriam-Webster, (n.d)). Numerous avenues are often used for marketing different products to children using television, radio, internet and print media. Selling food products carry over a large space of these media and generally concentrating on junk food products. Recently, more and more children b etween four and eleven years old are bombarded with unhealthy food advertisements during watching television or running online games which earn a legitimate worry for the government agencies. Such products should beRead MoreA Critical Analysis Of The Video On Advocacy Campaign Videos945 Words   |  4 Pagesand message conclusively (Group 10). On the other hand, the other group campaign that motivates me is â€Å"Axe the junk† that is helpful for people to learn that how the number of people suffering from different diseases in terms of diabetes, heart attack and obesity by taking junk foods. They defined junk food activities completely that help to influence others to take no more junk food to get rid of the illnesses. The role of the group members was competent and they capture images of the places thatRead MoreEating Environments Contribute to Obesity1692 Words   |  7 PagesFood and eating environments contribute to the increase in cases of not only obesity also chro nic diseases.Its a basic necessity of a child in their growing age to have a nutritious and healthy deit because of its delicious taste. However as it has been witness eating habits have shifted alaramingly over the last couple of decades. Fast foods such as burgers, pizzas,subways and many more are now commonly consumed foods in almost every household all over Pakistan now. Such foods originated in theRead MoreShould Cigarettes Be Banned in the U.S.?1400 Words   |  6 Pageshigh blood pressure, stroke, cancer, type 2 diabetes, scarring of the lungs, and bone density loss.† However, health implications caused by smoking is now considered common knowledge to society. By smoking cigarettes, the person abides to the understanding of the health implications and chooses to smoke out of his or her freewill. Smoking, on the other hand, does become a problem when a person wants to quit smoking, but cannot due to the addictive qualities. One could argue that once a person becomes