Evaluation of an
Established International
Health Partnership Using
Theory of Change
A report commissioned by THET
Suzanne Edwards
2016
Suzanne Edwards 2016
A report commissioned by THET
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List of Abbreviations
AAGBI Association of Anaesthetists of Great Britain and Ireland
AAU
Association of Anaesthesiologists of Uganda
CME
Continuing medical education
DfID
Department for International Development
GPAS
Global Partners in Anaesthesia and Surgery
HCW
Heath care worker
LMIC
Low and middle income country
LTV
Long-term volunteer
MCQ
Multiple choice question
MoH
Ministry of Health
MoU
Memorandum of understanding
NGO
Non-governmental organisation
NHS
National Health Service
OAA
Obstetric Anaesthetists Association
SAFE
Safer Anaesthesia from Education
THET
Tropical Health and Education Trust
ToC
Theory of change
TTT
Train the trainers
USA
Uganda Society of Anaesthetists
UK
United Kingdom
WFSA World Federation of Societies of Anaesthesiologists
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Executive summary
Context
Health partnerships are one method aimed at increasing health systems capacity in low and middle
income countries. Their complex nature makes evaluation difficult. Theory of change is one method
that is used to evaluate complex interventions and is becoming more widely used in the field of
health care. This report uses theory of change to evaluate an ongoing partnership between a
professional association of anaesthetists in the UK with one in Uganda.
Objectives
The objectives were to develop a theory of change to explain what works well in a successful health
partnership and why. How can an understanding of the mechanisms that underpin success in this
partnership be used to evaluate and strengthen health partnerships in general?
Method
.A theory of change was developed from the proposal for a project to deliver training courses to
anaesthetic providers in Uganda. This was compared to a theory constructed from stakeholder
interviews and programme reports of the completed programme to evaluate the partnership at an
organisational level, not just at the level of an individual project.
Results
The initial theory constructed from the programme proposal described a process in which
anaesthetic providers would be using skills and knowledge obtained from attending SAFE courses to
improve the clinical care of mothers and newborns. The final theory, constructed from stakeholder
interviews and project reports, describes a partnership developed largely but not entirely, on
Principles of Partnership, and based on a solid foundation of long standing links between individuals
who have built up a high level of trust, having greater than anticipated success in achieving project
goals.
Conclusion
Principles of partnership provide a sound basis for health partnerships but not all need to be met for
a successful partnership. Factors most strongly cited as contributing to success were long standing
relationships between key individuals in the partnership, which had developed a deep trust and
mutual respect over time, and the strength of vision for change held by the overseas programme
designer. Future areas of research should investigate the long-term sustainability of train the trainer
programmes. Also, theories of change for other partnerships that rely less heavily on the input from
a few individuals should be developed and tested to evaluate different types of partnerships.
Recommendations include inclusion of links with informal partners to be stated on THET project
proposals; better links between THET and volunteers; development of a theory of change for similar
projects transferred to new contexts.
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Contents
List of Abbreviations ............................................................................................................................... ii
Executive summary ................................................................................................................................ iii
Context ............................................................................................................................................... iii
Objectives .......................................................................................................................................... iii
Method .............................................................................................................................................. iii
Results ................................................................................................................................................ iii
Conclusion .......................................................................................................................................... iii
Background ............................................................................................................................................. 2
Questions addressed............................................................................................................................... 3
Method ................................................................................................................................................... 4
Results ..................................................................................................................................................... 4
Discussion.............................................................................................................................................. 21
Conclusion ............................................................................................................................................. 22
Implications for further study ........................................................................................................... 22
Recommendations ............................................................................................................................ 22
Acknowledgements............................................................................................................................... 23
Conflict of interest ................................................................................................................................ 23
References ............................................................................................................................................ 24
Appendix ............................................................................................................................................... 25
1
Background
The complexity of health partnerships makes their evaluation difficult. Theory of change (ToC) is an
approach, which is being increasingly used in the field of international development, for both design
and evaluation of complex interventions (1–3). Theory of change is a theory of how and why an
intervention will lead to proposed outcomes, which is arrived at by articulation and analysis of
assumptions held by program designers and stakeholders (1,2,4–6).
Evaluation of health partnerships often relies on measurement of outputs in terms of number of
people trained etc. rather than an assessment of the impact that training might have had. This is a
problem that has been associated with tools used to evaluate change in the wider field of
international development, which do not promote critical reflection but rather measure success in
terms of outputs, such as the number of people trained, rather than whether the training has been
effective (3). Theory of change is an approach that aims to be analytical and critical of how change
occurs and the impact it has. It has been found to be a particularly useful tool in complex programs
and partnerships, and in organisations that are well established (7). As yet the body of published
literature on the use of theory of change in health interventions in low and middle income countries
is small. A literature search for this report found four studies (1,8–10). These examples
demonstrate that ToC can be used to develop new interventions as well as to adapt existing ones to
new contexts or models of service delivery (9), as well as for ex-post evaluation purpose (1).
Evidence from evaluation of a ToC combined with experience of implementation can provide a
narrative of how an intervention worked in a particular context, which can provide details of
components of interventions that can be adapted for use in different settings (9). There is no single
process for developing a ToC and methods used can include workshops or interviews with
stakeholders and review of relevant documents (1,11). The Aspen Institute Roundtable on
Community Change published a process for developing a ToC for complex community interventions,
which involves workshops with key stakeholders, working backwards from an agreed long-term
outcome to determine outcomes that must be achieved in order to reach the long-term goal (12).
The links between actions and outcomes are displayed in a ‘pathway of change’, or a ToC map, and
the theory is explained in a narrative summary. The terminology and the format of the ToC map
used in this report are those developed by the Aspen Institute. Terminology is described in table 2.
The process begins with determining the long term outcomes that the stakeholders want to achieve
and mapping backwards from there, determining what pre-conditions, or outcomes, must be met at
each stage in order for subsequent outcomes to be met. At each stage interventions that are
needed to bring about change are identified. Indicators are described to objectively determine if
each outcome has been met. The aim is to articulate a causal pathway leading from the inputs to
the outcomes. Evidence, which may be from literature or experience, supports the rationale for
each link in the pathway and frames the assumptions that are made as to how change is going to
happen. The different levels of a ToC are illustrated in figure 1.
The aim of this work was to develop an organisational level theory of change for an established, high
quality health partnership as an aid to: evaluate implementation; understand the mechanisms of
change and the context of international health partnerships; as a tool for planning future projects
and partnerships. The criteria for judging the quality of the partnership were the Principles of
Partnership advocated by THET (13), they are listed in appendix 1. These principles are themselves
underpinned by various assumptions, which are to be investigated in this study.
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Figure 1. Theory of change stages
Ceiling of accountability
Interventions
Preconditions/
early outcomes
Preconditions/
intermediate
outcomes
Long-term
outcome
Ultimate
outcome
The partnership between the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and
the Association of Anaesthetists of Uganda (AAU), which was formerly known as the Ugandan
Society of Anaesthetists, was started in 2006. Since then it has implemented several projects in
Uganda, which have received funding from THET, and the partnership is ongoing. The main project
analysed in this report ran for two years between 2012 and 2014. The project provided training
courses on obstetric anaesthesia for anaesthetic practitioners in Uganda and its goal was to deliver
training to all providers of anaesthesia in Uganda over a period of two years.
One approach that has been put forward for classifying health partnerships is to group them
according to: their intended impact (whether at individual or organisational level); approach to
health systems strengthening (training and education alone or coupled with infrastructure
development; specialist or generic skills and knowledge); and relationships (equal or unequal)(14).
Using this typology the project between AAGBI and AAU would be categorised as having an impact
at the individual level, with infrastructure development and specialist health care as its approach,
with equal scope of influence between partners. This classification could potentially be useful both
for design and evaluation of international health partnerships if it could be shown that similar
theories of change operate within each category.
Questions addressed
The questions to be addressed are:

What works in this partnership and why?
This is to be answered through the development of a theory of change that answers the following
questions:




What causal mechanisms are believed to link the inputs and outputs of the partnership
between the AAGBI and the AAU?
What assumptions underpin these causal mechanisms?
What evidence is there to test these assumptions?
In regards to the SAFE obstetric anaesthesia project: how did the actual implementation
and outcomes of the programme compare to those put forward in the initial proposal?
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
What can be learned from this partnership to strengthen other health partnerships?
Method
The approach used to develop the theory of change used a process developed and described by Van
Belle et al in which they used available documents, interviews with stakeholders and evidence from
similar interventions to inform the construction of an initial and a revised theory of change(1). In
this study the initial programme proposal for a project to provide training in obstetric anaesthesia in
the form of SAFE courses for all providers of anaesthesia in Uganda was examined for proposed
inputs, outputs, causal links between them and assumptions that underlie them to develop the
initial programme theory. For the revised theory, data came from interviews with stakeholders,
project reports and a focus group with participants from the funding body (THET), and the theory
was more at the organisational level rather than being restricted to the programme level.
Interviewees were selected to include programme designers and implementers from the UK and the
overseas partners and a range of staff from the funding body. Semi- structured interviews were
conducted either face to face, by Skype or telephone. In total five AAGBI members who included
programme designers and implementers, two AAU members who are both designer and
implementers and three THET employees involved with volunteer engagement, programme
management and evaluations, were interviewed. Of the 12 people invited to participate one
declined and one did not respond to invitations. All participants gave verbal informed consent.
Interviews were recorded and transcribed.
A topic guide was used for the interviews that aimed to draw out information on the inputs provided
by each participant; their interactions and relationships with other stakeholders; goals of the
partnership; changes that need to happen to reach the goals; what makes the partnership
successful; the main challenges in bringing about change; impact of the partnership and
unanticipated outcomes. Assumptions were identified and the literature was searched to see if
there was any evidence to frame them against existing theory and articulate a rationale for how
change would occur. The focus group examined assumptions around the Principles of Partnership
and THET’s engagement with different stakeholders involved with partnerships.
Data were analysed using a framework approach in which data are organised into main themes and
emergent categories (15). Category codes were developed from the themes and used to code the
data. Coded extracts were put into a Microsoft Excel spreadsheet where they could be arranged
according to codes.
Results
The themes that emerged from the stakeholder interviews, which were subsequently used to code
the data, and how they are linked to the refined theory of change are shown in Table 1.
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The initial theory of change narrative for SAFE obstetric project developed from the funding
proposal: After several years of links between anaesthetists from AAGBI and anaesthetists in
Uganda the project was set up between AAGBI and USA to provide training in obstetric anaesthesia
for all anaesthetic providers in Uganda. In Uganda the majority of anaesthesia is provided by nonphysician anaesthetic officers who, prior to the introduction of the SAFE courses, may not have had
Table 1. Coding strategy
Themes
Involvement with
partnership
Sub-themes
Link to theory
Existing links: Long-term relationships,
individuals, trust, mutual respect
Links with other organisations
Confidence to engage with UK partner
Role of the
partnership
Responding to Ugandans
Advocacy for anaesthesia
Building on achievements
Development of the profession
Accelerating development
Personal/individual factors: Close
personal links and interactions; linking
with the right people; personalities;
strong leadership; friendship; ease/
comfort at communicating
Formal/ group factors: Long-term
volunteers; passing on the baton/
responsibility for continuity &
perpetuating gains; equality between
partners; mentoring; advocacy;
improving links between Ugandan
cadres & anaesthetists; dissemination
of skills and knowledge beyond Uganda
Relationships
Long-term changes
needed
Development of individuals:
More doctors; professional
development,; career progression
Development of profession:
Development of professional status
Development of infrastructure:
Links to/ input from other organisations;
government input; funding; embed
training in curriculum
Main challenges
UK limited: Lack of UK personnel in
Uganda
Uganda limited: Organisational
difficulties for courses in local context;
unpredictability of working in Uganda;
delayed communications; getting
government input; finance; lack of
infrastructure
1
Recruitment of suitable, experienced
volunteers; collaboration to avoid
duplication of activities
The programme is owned by the
overseas partner and the UK partner
supports and enables the goals to be
reached sooner than if they were
working alone
Linking with the key people with the
contacts and ability to implement
change
A pool of long-term volunteers
committed to international
development is able to adapt support
and training to local context.
Fostering a sense of responsibility in
recipients of training creates
sustainability.
Training of anaesthetic officers
provides a ‘stop gap’ until enough
physician anaesthetists can be trained
to provide anaesthesia in all areas of
Uganda1
Government input is needed to
provide finance to embed SAFE course
into the curriculum so that is can
become sustainable and independent
of UK partner
Isabeau Walker notes that “‘Task-sharing’ between physician and non-physician anaesthetists is required to provide
anaesthesia in all areas of Uganda.” (Comment added after report was finalised.)
5
any refresher training since they qualified. In the rural areas anaesthetic officers are usually the sole
providers of anaesthesia, with most of the physician anaesthetists, who are relatively few in number,
being located in the urban areas. A large part of the workload of anaesthetic officers is obstetric
anaesthesia. Uganda has a high maternal mortality rate. There is a need for more, better trained
obstetric anaesthesia providers in Uganda.
The long-term goal of the project was to increase the clinical capacity of the whole Ugandan
anaesthesia workforce. The project aimed to achieve this by providing training for Ugandan
physician anaesthetists to become trainers capable of delivering short courses, SAFE courses in
obstetric anaesthesia, to all providers of anaesthesia in Uganda over a two year period. This was
based on several assumptions: that anaesthetists would be able to attend the courses; the courses
would train anaesthetic providers to a high standard of obstetric anaesthesia, skills and knowledge
would be retained and workers would change their practice; appropriate resources would be
available; the trainers and those trained would stay in anaesthesia in Uganda. Some of these
assumptions were justified by evidence from courses of a similar length that had been delivered in a
different context. The last one by trainees being engaged in their posts for the next two years.
The theory was that providing training to anaesthetic providers would improve their skills and
knowledge, hence the anaesthetic care provided to mothers. Assumptions were as follows:
A.
B.
C.
D.
E.
F.
G.
H.
Ugandan workers can be released from work for training
Statistically significant change in knowledge score equates to a relevant effect size
Trainees retain skills & knowledge
Trainees stay in post
Resources are provided to implement improved skills and knowledge
Workers change their practice
Trainers retain their skills and knowledge
Trainers stay in post
Interventions needed were the following:
1.
2.
3.
4.
5.
AAGBI and USA members collaborate to design programme
AAGBI raise awareness among members to recruit volunteers
Ugandan partner raises awareness to recruit trainees
Ugandan partner arranges release of course delegates
Training of Ugandan trainers
The initial theory of change map is illustrated in figure 2.
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Table 2. Terms used in Theory of change (adapted from De Silva 2014)
Terminology
Impact (ultimate goal)
Long-term goal
Precondition (outcomes)
Ceiling of accountability
Indicator
Intervention
Assumption
Rationale
Definition
The real-world change you are
trying to effect.
The final outcome a
programme is able to change
on its own.
An outcome on the pathway to
achieving the long-term goal.
Intended results of the
interventions.
The level at which you stop
using indicators to measure
whether outcomes have been
achieved and therefore stop
accepting responsibility for
achieving those outcomes. It is
often drawn between the
long-term and ultimate goals.
Things that can be measured
to determine whether
outcomes have been met.
An activity that is needed to
bring about change.
A dotted arrow is used to
show when an intervention is
needed to move from one
outcome to the next.
A solid arrow is used when one
outcome logically leads to the
next without the need for any
intervention.
An external condition beyond
the project that must exist for
the outcome to be achieved.
Key beliefs that underlie why
one outcome is an outcome
for the next and why you must
do certain activities to produce
the desired outcome. Can be
based on evidence or
experience.
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Example
Safe and effective anaesthesia
in the whole country.
Better skilled, more
knowledgeable anaesthetic
workforce.
Trained trainers.
The ultimate goal is to increase
the clinical capacity of the
whole anaesthetic workforce
but the partnership does not
accept responsibility for
achieving this on its own.
Number of delegates
completing a course
Awareness programme to
recruit volunteers.
Training of trainers is a
sustainable model.
Health care workers must feel
valued in order to improve
their work performance.
Figure 2. Initial theory of change map
Ultimate outcome: Increased clinical capacity for the whole of the Ugandan anaesthetic workforce
Ceiling of accountability
Anaesthetic officers
deliver improved
anaesthetic care of
mothers undergoing
caesarean sections
Improved care of
mothers undergoing
anaesthesia for
other conditions
F
Anaesthetic workforce trained to a high standard
in obstetric care (have increased skills &
knowledge)
B
A
Ugandan course
3
E
D
C
1
Improved
resuscitation and
early care of the
newborn
Improved critical
care of mothers
E
G
H
SAFE courses delivered
A
participants recruited
A
1
4
Trained Ugandan trainers
Courses piloted
1
1
4
5
UK volunteers recruited
Courses designed
Ugandan trainers recruited
1
2
Links between partnership
and THET
1
Partnership set up between
AAGBI and AAU
AAGBI
3
Partnership with additional
partners OAA, WFSA,
Lifebox
USA
1
1
Key
Domino effect
Assumption
Organisation
Intervention needed
Intervention
Outcome
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The refined theory of change narrative: The partnership received funding from THET and it was
considered to be based on the Principles of Partnership. A long standing relationship between
AAGBI and AAU built on trust and mutual respect between key individuals provides confidence for
collaboration:
“We have many, many collaborations, I have so many young people. You tell
them that, ‘You know we are going to work with such and such group of people’,
and they are doubting you, yet you tell them ‘We are going to work on this with
such and such people, let’s go and meet X and Y [AAGBI members] in Masaka ‘,
everybody’s happy to meet them. They trust them. They know that they are not
going to use them. They will come and do everything with all their heart. It is
very, very important to build a relationship. If you don’t do it you are wasting
time.” (AAU designer)
The fact that the inputs from the UK partner are led by what the Ugandans want gives ownership to
the overseas partner and they participate with enthusiasm:
“What I would like to encourage is we continue with the collaboration and the
communication, and I like it, but most of the time when something needs to be
done the local faculty are consulted, which is a very good thing, so when that is
done, which I encourage to continue, because the people on the ground feel they
own it and their interests are being considered, so it is one thing that I encourage
to be continued, because it matters a lot, otherwise if they don’t do that, or it
stops happening, the local can easily withdraw because they’ll think, after all, it’s
not us.”(AAU implementer)
The importance of the interventions being Ugandan led were recognised by both partners:
“A lot of it’s responding to what X [Ugandan designer] would like us to do”
(AAGBI designer)
“…we have tended to try and work as … all the time trying to work as much as
possible as to what X [person named] wants us to do, and if he says: ‘That’s not
what we want to do’, then with them we don’t. It’s not that we don’t come with
new things to the table. It generally does seem to be that we come with a
suggestion and X says: ’Yes, that will work’, or ‘that’s a good idea’, and is X the
one who is driving the change? Certainly enabling it, certainly the driver for the
initial project: we need more doctors. That was very much X’s vision.”(AAGBI
designer)
“…a lot of this has been driven by the AAGBI but they have … made absolutely
sure at every step that it’s sort of owned and led by anaesthetists on the ground,
so anaesthesiologists on the Ugandan side.” (AAGBI volunteer)
A strong leader in Uganda, who has a strong vision for change, and who is highly respected by
Ugandan staff is able to garner support for participation of anaesthetists in the programmes and
arrange their release from work for attendance on courses.
9
“I think the beauty of this partnership is we’re very lucky to have someone like X
who has a strong vision for his own country” (AAGBI volunteer)
“…we have our thoughts but we are mainly guided by what he requires and what
he thinks is a step forward and he sort of comes up with it and we, you know, or
we come up with proposals such as SAFE and then he agrees, so it’s sort of a
partnership, and I believe strongly it’s because he’s got such strong leadership
and such good partnership with AAGBI.” (AAGBI volunteer)
Links with other organisations connected to Uganda enable sharing of inputs while avoiding
duplication activities in anaesthesia. of
“…we’ve been able to collaborate with also Lifebox project, and we’ve got many
pulse oximeters all around Uganda. We’ve been able to train the clinic officers
to use the pulse oximeters in collaboration with AAGBI faculty.” (AAU
implementer)
“I think it’s also about linking with other players in the field, so we are aware
that in Uganda there are many other organisations that are working in Uganda
and we’ve always been very careful to link up to them so that we all work
together so that we don’t, we don’t overlap… each organisation has had
something different to offer. The success of anaesthesia in Uganda is not
just the AAGBI.”(AAGBI designer)
Other organisations also provided a pool of long-term, highly motivated volunteers with an
understanding of how the system works in Uganda.
“…the teachers you get from these long-term volunteers are very good because
they already know what it’s like, what the resources are, you’re not trying to get
UK people who have never faced this before, and these teachers also, they are in
Uganda for a reason, they are enthusiastic and individuals who feel strongly
about the developing world, so you get a group of really enthusiastic volunteers
to teach, who probably might have their own ideas on how the course could
develop because of what they’ve seen and experienced, and also, more
importantly they understand the culture of the people after having been there
for a while and make less faux pas.” (AAGBI volunteer)
Face to face meetings of anaesthetic officers and physician anaesthetists during courses have
highlighted difficulties faced by the officers and their lack of support and supervision, which has
resulted in better understanding by the physicians together with a willingness to do something to
improve the situation.
“…we didn’t realise that there was such a disconnect between the
anaesthesiologists - the doctors , and the anaesthetic officers, and so for the
SAFE course they were suddenly sitting in the same room together, because it is
all small group teaching, the anaesthesiologists are hearing what it’s like to work
in a rural hospital. The anaesthesiologists never go to those hospitals, and
whereas they used to be very dismissive of problems faced by the anaesthetic
officers saying ‘they don’t do this, they don’t do that’, suddenly understand what
10
it’s like, so they then end up as better advocates for anaesthesia in their
country,”(AAGBI designer)
Interest shown in the work of the anaesthetic officers by AAGBI members and Ugandan physician
anaesthetists has increased motivation of the anaesthetic officers. This is supported by literature
identified in a review of interventions to manage health care worker performance in LMICs, which
also identified a feeling of obligation to change as being important(16). One of the volunteers
identified this as an important aspect of their role in Uganda:
“…for those anaesthetic providers to know that people outside of their
immediate hospitals take a great interest in what they do and have a huge
amount of respect for what they do and I think that’s almost as important as the
main skill we teach.”(AAGBI volunteer)
Support received by Ugandan anaesthetists from AAGBI for training has created a sense of
responsibility to perpetuate training and improve anaesthesia in Uganda.
“…because they started with the SAFE course they are already willing to go and
participate in that because it was started when they were still residents, so no
matter if it was AAGBI they still keep on doing it regardless of the organisation
that is continuing it, so it is something that is good, it puts them into the spirit of
helping the people who are in far to reach areas.” (AAU implementer)
“Only when they met these people they see how difficult their lives are, they see
how they yearn for the knowledge and all that, which is kind of something that is
eye opening to everyone, and then people take it on, they feel like, you know, I
think I want to go next year, I want to help these people, I want to come again
next year. So that’s why we involve residents so much, which helps the residents
also to see anaesthesia and all that work they see in their training, anaesthesia is
so much bigger than what they are looking at….the whole trick is basically
involving people, it is basically showing people that this is necessary, you know,
it is part of your responsibility.” (AAU designer)
This has resulted in physician anaesthetists remaining in the country, also a few moving away from
the main urban areas to support anaesthesia in less developed areas.
There are some, there’s one in Mbale, …there’s an anaesthetic doctor in Gulu, so
they are spreading around the country.” (AAGBI designer)
Training of a critical number of trainers has resulted in the running of SAFE courses being largely
taken over by the Ugandans and becoming embedded in the training schools’ curriculum. There are
now a greater number of physician anaesthetists in Uganda as a result of AAGBI fellowships.
“…about six years ago there were about eleven anaesthetists, physician
anaesthetists in Uganda with about three or four residents. At the moment as I
speak there are about forty residents and coming close to forty-five specialists.”
(AAU implementer)
11
Raised status of anaesthesia in Uganda, which has been brought about by the creation of a
professional association and development of anaesthesia as a speciality, along with involvement of
individuals in international conferences is attracting more doctors into anaesthesia:
“…they’ve now moved from the Ugandan Society of Anaesthesia to the
Association of Anaesthesiologists of Uganda. For us that’s an amazing end point
because they now have an association…the whole status of anaesthesia has
changed…they had their first scientific meeting two weeks ago...it was led by
Ugandan anaesthetists, they had the Kenyan anaesthetists coming to support,
they had some anaesthetists from Swaziland, somebody from Tanzania, so it’s a
thriving anaesthesia, medical society. It’s extraordinary actually. It changed.”
(AAGBI designer)
“…because we’ve been having foreign faculty coming in, not just financially, but
even AAGBI has been able to bring in people and showing people there are other
people who care, the numbers of people coming in to train for anaesthesia has
greatly improved and increased.” (AAU implementer)
Improved expertise in teaching and training as a result of delivering SAFE courses has enabled
Ugandan anaesthetists to assist in dissemination of gains to other countries in Africa.
“…the Kenyan Society are very, very keen to develop the obstetric course
throughout Kenya, so the Ugandans are going to go to Kenya to help set up
those courses, and we’ll go as well, but it’s essentially the Ugandans who are
now the experts,…the SAFE course is spreading elsewhere. In a way, we knew it
had the potential to do that. Did we set out to do that? No, I think we’ve been
overwhelmed by the success of the partnership, just how good the anaesthetic
doctors are in Uganda, they are quite astonishing.” (AAGBI designer)
Experience of teaching and managing people on SAFE courses has given AAGBI volunteers skills and
qualities that are desirable when they return to work in the UK.
“Education is one thing that they’ve [AAGBI] funded fairly well because they
know of the benefit that it can have to the Ugandans but also benefits to its sort
of members, back here people like me, people who will get a lot out of it and go
on to be better anaesthetists, better consultants in the UK. I guess that’s
possibly why they’ve done that instead of handing over a whole lot of cash and
saying why don’t you get yourself an oxygen supply, or whatever it is.”(AAGBI
volunteer)
Links to governmental organisations are leading the way for the work of the partnership to become
sustainable in the long-term:
“…he [AAU designer] now has a group of doctors who will be saying ‘We need
this, we have to have that’, and I think for us that is something we could help
with as well through links really, I’d quite like to link to the DfID in-country office
in order to be able to speak to the Ministry of Health,” (AAGBI designer)
12
The refined theory of change map is illustrated in figure 32.
2
Isabeau Walker notes “The aim of the SAFE course is to provide high-quality continuing medical education (CME) for
trained AOs, rather than to shorten their training. The SAFE course will not increase the number of anaesthetic doctors per
se; probably better to say increased number of skilled healthcare workers providing anaesthetic care in Uganda.”
(Comment added after report was finalised.)
13
Figure 3. Refined ToC map
Ceiling of accountability
7
1
2
1
1
2
1
6
1
3
1
2
1
5
1
1
2
1
4
Key
Domino effect
Intervention needed
Assumption
Intervention
14
Organisation
Outcome
Assumptions that underpin this theory were identified as follows:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Principles of Partnership provide a sound basis for health partnerships
AAGBI has something to offer AAU
Lack of funding is limiting factor for training in anaesthesia in Uganda
Fellows will stay in post/country
Ugandan Ministry of Health will take on responsibility to fund training
Training of trainers is a sustainable model
UK teaching & training methods are transferrable to Ugandan context
A three day course is sufficient to make an impact on anaesthesia
Change is caused by a small number of individuals
Health care workers need prospects of career progression to be motivated to perform their
roles effectively
Interventions are listed below:
1. DfID provides budget for THET
2. AAGBI communicates with THET to apply for grant, THET gives advice and guidance on
partnerships
3. AAGBI recruits volunteers, volunteers apply for posts
4. NHS enables opportunities for volunteers, volunteers return and work for NHS
5. LTVs work for other organisations
6. AAGBI makes contact with LTVs working with other organisations
7. Key individuals AAGBI and AAU form partnership
8. Funding for fellowships
9. Human and material resource provided to train trainers
10. Trainers run SAFE courses
11. AAU arranges with MoH to embed SAFE courses in anaesthetic officers’ training colleges
12. AAGBI makes contact with DfID in order to link to MoH in Uganda
The assumption that Principles of Partnership provide a sound basis for partnerships was explored in
a focus group with participants from THET. They described a process of assimilation of anecdotal
evidence, information from case studies and institutional memory from people involved in the
health partnership sector to arrive at the current Principles of Partnership and hallmarks of good
practice. These are a set of guiding principles for those involved in setting up health partnerships
(see Appendix 1 for a list of the Principles of Partnership). The first of the principles is ‘Strategic’,
which states “Health partnerships have a shared vision, have long-term aims and measurable plans
for achieving them and work within a jointly-agreed framework of priorities and direction”(13). The
partnership between AAGBI and AAU fulfils these aspects, however some more detailed aspects,
such as having a Memorandum of Understanding (MoU), do not seem to have been a contributing
factor to its earlier success:
“…after all these years, and it is quite a long time, we’ve only just got around to
signing an MoU… I think it’s important we do it, but have we not achieved
because we haven’t done it? No. But I think it’s probably as much to do with the
individuals involved, that there was always a sort of respectful understanding on
both sides, that we would work in a collaborative way, that we’d respond to
need, you know, and all those sorts of things, but for the organisations, yes
probably, as time goes on it is important to get it organised and get it done, but
particularly as individuals involved then move on, the organisations need some
sort of finality. I guess it’s important.” (AAGBI designer)
15
“…that’s how things come up, you’re just having tea, and then you discuss ‘oh,
how can we go about this?’ People throw ideas here and there and somehow an
idea comes up and then you refine it and it comes to pass.” (AAU designer)
“Well to be honest with you, many of these things, I’m just honest, there’s
nothing that we sat there and really set goals and said we must do a, b, c, d, but
sometimes, like SAFE course we started with one course – OBGY, half courses got
over hundred people, and within a short time we had actually cleared almost
everybody in the country had done the course. I didn’t expect that that was
going to happen, but when people start, then a lot of energy comes in, a lot of
enthusiasm comes in.” (AAU designer)
“Allow things to grow over time, don’t have ambitious plans and say ‘I will do
this, I will do this’. And, you know, …there are so many problems if you set
yourself goals, many times so many goals are going to be unrealistic, yet if you
have a very strong relationship many goals are going to be achieved even
without you setting them – we’ve seen it happen. It’s very important.” (AAU
designer)
The above quotes illustrate the evolving nature of the partnership and the need for flexibility, which
is one of the Principles of Partnership
The principle that partnerships should be ‘Harmonised and Aligned’ is strongly demonstrated in this
partnership by the close collaboration with other organisations working in the same area to
maximise effectiveness:
“…the thing is, you know, somehow all these people are the same people…it has
been basically something that has been passed on from one group to another”
(AAU designer)
The ‘Effective and Sustainable’ principle assumes that a train the trainers model promotes
sustainability in a project. This was assumed to some extent by all parties:
“…our hope is that once we have that pool of local instructors we know they’ll
reduce their reliance on UK volunteers” (AAGBI volunteer)
“…the difficulty we have I suppose in kind of showing that a training of trainers
approach clearly leads to sustainability …that does partly reflects the difficulty
we have in collecting data, and that’s kind of implicit in a way in this training of
trainers, …the idea is that people who are trained as trainers will then be able to
go off and either, well, sometimes, who knows, they’ll be able to go off and more
or less independently - they may need resources, they may need support - they
will take the initiative and run courses as appropriate and actually, if they don’t
report back to the people who trained them, or the project, arguably that’s a
good thing, that’s a sign of kind of independence and that the thing is
embedded.” (THET staff)
The above assumption is supported from comments from Ugandan trainers:
“…ever since we started the partnership with the AAGBI and the SAFE courses
many of our residents have managed training and also being involved in
teaching and all that, and with that initiation of that, and most of them are
16
working with self-initiative, participating in all these things no matter where they
go.” (AAU trainer)
A study showed that 67% of trainers trained under a train the trainers model went on to become
trainers, with attrition rates increasing as the number of courses trainers went on to teach increased,
the number teaching 4 or more courses fell to 34% (17). This was similar to the figures provided by
an evaluation of TTT programmes in different contexts, which reported 50% to 70% going on to
become trainers (18). The AAGBI – AAU partnership has been successful in training effective trainers
but sustainability in terms of financial and other resources is less clear:
“ I think when things are left to them, when they are so lacking in resources I
think it all takes a lot longer than having external courses.” (AAGBI volunteer)
“…the local facilitator have now taught on so many courses with myself and I
believe in their ability to do so, it’s just now finding infrastructure to make that
sustainable.” (AAGBI volunteer)
TTT is recognised as needing more than just educational input to promote sustainability in a
programme:
“We had one grant that trained trainers and they didn’t get commitment from
the overseas management that they would actually then support the training
and now they’ve delivered all this trainer training, delivered a number of training
courses, the partnership has also delivered a number of training courses and now
the hospital has kind of gone: well you trained everyone, so we’ve got no need to
continue this and they are not willing to support those trained trainers to then
continue to deliver training.” (THET staff)
The literature has documented that an advantage of using a train the trainer approach is
having local trainers who are better able to adapt training methods and materials to suit the
local context (17). This was also reported in this study:
“…the Ugandan anaesthesiologists have been really, really involved then at
delivering that and being involved in tweaking the course where they think it’s
more relevant to what they actually do on the ground and so on,” (AAGBI
volunteer)
There is relatively little contact between THET and the overseas partners and there seems to be an
assumption that UK and overseas partner are communicating effectively, but this may not always be
the case:
“Oh yes, for us we have benefitted. I don’t know, I have not cross examined
AAGBI, but we’ve benefitted… I guess all those encounters that we’ve had we’ve
gained a lot, but actually it could be, it would be very interesting to hear from
many people from AAGBI. Probably they have also gained a lot, so that’s why
I’m like, either way everybody gains.” (AAU designer)
On discussion with THET on the equality of relationships between partners and them being
respectful and reciprocal it emerged that this is not always the case between partners, with some
grant applicants assuming any intervention is better than none:
17
“… we’ve got a product and they’re bound to want it. And I always just…no,
they’re not bound to want it, you know, so I guess it’s an assumption that as the
UK partner, or even perhaps potentially us that as the partnership, and it is the
big hospital, the district hospital, the regional referral hospital has kind of got
this product that worked, and all the kind of small clinics around it will naturally
want it without actually having had the conversations with them to see if that’s
the case.”(THET staff)
This was echoed by one of the Ugandans interviewed when asked about the balance of influence
between the partners:
“…they’ve [AAGBI] got to have something to offer, I don’t really see anything
that serious, as long as somebody doesn’t order you around and say you do a ,b,
c, d there is no problem. As long as you sit all around table and you agree that,
you know, probably our next move should be a, b, c, d, then everybody respects it
and probably that has been the clue” (AAU designer)
The Ugandan partners reported gaining a lot from the partnership with AAGBI and felt that the
partnership was equal:
“…the skill set is one of the most important things, and then also trying to
mentor. Mentorship is another thing. So apart from the financial benefit it is
also mentorship of the local young faculty around here.” (AAU implementer)
“I’ve been working with some people in terms of my academic growth locally,
but with having them giving some input and advising me on a, b, c, d and OK
what to do, and even in terms of research and collaboration, not just looking at
things that are like SAFE course but even if, like for example I wanted to do some
research, collaborative research, that is one other thing that I’m trying to look
at,” (AAU implementer)
The assumption that lack of funding is the limiting factor for training in anaesthesia in Uganda was
held by interviewees who described the situation in Uganda where doctors who want to become
anaesthetists have to pay for their training in contrast to those that enter other specialisms. When
asked about what made the partnership so successful one Ugandan thought it was the financial
input:
“The truth is that most of the residents actually depend on that[financial]
support, which keeps them going so they concentrate on their books knowing
there is something coming from AAGBI,” (AAU implementer)3
Although finance was mentioned as necessary by all interviewees this was not seen as the main
cause of success by most interviewees:
3
Isabeau Walker notes “This is referring to the AAGBI Fellowship programme whereby we pay an annual
stipend to support physicians to train in anaesthesia. [AAGBI] do not pay per diems to anyone attending the
SAFE courses.” (Comment added after report was finalised.)
18
“… it’s not money dependant it’s dependant on the enthusiasm and the
motivation of individual people and while that’s there I think that will
continue.”(AAGBI volunteer)
“The best thing that has happened to us is probably nobody is interested in the
money, they are interested in what are we going to do and what are we going to
achieve? And I think that money does not appear anywhere because we don’t
have any issues. All we have to do is, can we see all the ideas are linked up
together? OK? That’s what is important. Once you see that, the issue of money,
all those people trying to say how much are we getting and all that, and I’m
clearly saying to you, and everybody knows it clear, and we’ve even told the
anaesthetic officers, when we take them out for training we shall never, not even
ever, even if there had been money available, for us as the AAU we are saying
we are not going to pay anybody.” (AAU designer)
Loss of trained staff, either to other countries or to other parts of the workforce is a well-recognised
problem in LMICs (19,20). The risk of fellows leaving the country was recognised by the AAGBI but
for the programme to work there would have been the assumption that the majority would stay.
“A few have gone to Kenya, one went back to Sudan, because that is where they
were based, we were worried that people would disappear and that they would
leave the country, but they’ve all stayed locally.” (AAGBI designer)
A literature review on staff attraction and retention in LMICs identified a positive correlation
between staff retention and opportunities for professional development (19), many of the
comments from the interviewees seem to support this. Several of the assumptions underlying this
ToC such as UK teaching & training methods being transferrable to Ugandan context; health care
workers needing prospects of career progression to be motivated to perform their roles effectively
are supported in the literature (16). Many of the factors identified as motivating health care
workers in that realist review echo those that emerged from this study, mainly greater awareness of
local problems empowering people to make changes; a sense of belonging and respect; witnessing
success and feeling a sense of obligation to change.
Anaesthesia is highly dependent on provision by anaesthetic officers in Uganda due to the small
number of anaesthetic physicians. They are often the sole providers of anaesthesia in rural areas
and may not have received any training since they completed their training.
“…all of these workers, sometimes they’re not paid for months on end, and they
end up having to have different businesses and different projects so they don’t
care enough. So I think being able to come in and say: ‘you guys are doing a
fantastic job and we really, really recognise that and we know how difficult it is
for you and you’re doing an amazing job’, it is a very powerful outcome and
something I didn’t really think too much about before I was there.” (AAGBI
volunteer)
Research in has shown that appreciation by colleagues, managers and the community and
opportunities for professional training are motivating factors for skilled health workers in LMICs (19).
Motivation has been reported as an important factor in addition to improved knowledge and skills in
implementing change in the performance of health care workers (16). This is also apparent from this
study.
19
Another assumption was that a three day course would be sufficient to make an impact on
anaesthesia. This seems to be supported from feedback from interviewees, although the difficulty is
assessing skills is acknowledged and the fact that continuing education is needed:
“…you find out they [anaesthetic officers] haven’t had CMEs [continuing medical
education] in like seven years, from the time they graduated, so with the start of
the SAFE course and all that, that’s helped us improve on their knowledge and
also improvement on their skills, though the skills part, the clinical part is difficult
to measure since we are not always there with them at work, but if we do like –
if you involve yourself in conversations regarding things that we’ve been
teaching the knowledge base is much better.” (AAU implementer)
“well a few of them have come over to present things at meetings in the UK as a
result of it, a huge benefit to their professional development, and then the
anaesthetic officers, the nurse anaesthetists I think benefit a lot from the
knowledge they learn, if you look at the skills they get out of it, and then you
look at the feedback weeks or months later about how much they’ve got out of
coming to a course like that it’s huge” (AAGBI volunteer)
“I saw the outputs from this because I went back to these hospitals after to
work,” (AAGBI volunteer)
“one would hope that delegates being trained benefit because I think it’s
important to remember that actually this is just a short course, 4 day courses
need continuing to help them in their training,” (AAGBI volunteer)
The long term sustainability of the successes of this partnership relies on the assumption that the
Ugandan Ministry of Health will take on responsibility to fund SAFE courses:
“…we are not saying that these courses will be there always followed by AAGBI,
for example SAFE obstetrics, we think that is out of AAGBI sponsorship but we’ve
been given, we’ve been armed with responsibility now to move it on. And what
we’ve decided to do, that the easiest way of doing it is we are going to take it to
the anaesthetic officers’ schools.” (AAU designer)
There is an assumption that change is caused by a small number of individuals. The stakeholder
interviews give a strong sense that success has been due to a few key individuals in this partnership.
“Without those 3 individual people I think a lot of this wouldn’t have ever
happened and that continues to be the case although now there are additional
people such as myself…”(AAGBI volunteer)
The fact that relatively few people from the UK are overseas at any one time was cited as one of the
challenges faced by the partnership, but in spite of this the partnership has been successful.
The initial ToC explained how the project to provide SAFE courses to the anaesthetic workforce
would improve the outcomes for mothers undergoing anaesthesia and their newborns. The refined
ToC explained the pathways to success for the project but also the pathways that underpin the
partnership as a whole. The data from the stakeholder interviews added the role that motivation of
health care workers plays in retention and recruitment of staff in anaesthesia; the importance of the
20
development of a professional association to raise the status of anaesthesia to a specialism within
medicine, which attracted more people to train as anaesthetists; the importance of a strong, trusting
relationship between partners to implement changes.
Discussion
A real strength of this study was that participants from the health partnership have been involved
for many years, some from the outset and are still currently involved, which gave good insight to the
origins and the development of the partnership over time. The stakeholder interviews gave a lot of
detailed information, however, individual interviews rather than group sessions for participants
missed opportunities for shared ideas and discussion of opinions. Another limitation was the small
number of people interviewed from the Ugandan side of the partnership.
Some of the data have provided evidence that TTT is effective in educational terms, but that
education alone is not enough to make it a sustainable model. There is little published literature in
this area and length of follow up is about 3 years (17), so long term investigation is needed.
Problems highlighted include burn-out, toll of extra duties and dilution of training (17,18).
Many of the themes that have emerged from this study are consistent with those identified in a
realist review of human resource management interventions in LMICs, for example motivation,
recognition, professional development (16). Use of ToC is becoming more widespread in planning
and implementing complex health interventions (9,10,21)and these examples are a good illustration
of the potential for this tool to be used more widely by health partnerships. For the AAGBI and AAU
it could be particularly valuable before disseminating SAFE courses to different contexts, such as
different countries in Africa, either in partnership with each other or with other partners. This could
be important due to the different links between key participants:
“For me, we’ve had such strong links with Uganda I kind of think we should
move on into developing, help support anaesthesia in additional hospitals,
embed what we have got already rather than thinking we can start somewhere
else because, actually we don’t have those personal links.” (AAGBI designer)
What comes across very strongly in this case study of a health partnership is the importance of a few
key players. Is this a problem or a model for a successful partnership? A very pertinent quote from
one volunteer maybe has the key to this:
“I think my main sort of take home message personally from it is how powerful a
personal link can be … It’ just the fact you can get so much out of people, out of
projects if you have basically strong personal relationships and links that have
been, sort of, maybe built over years, but they are the key to getting things done,
and I think that’s probably the case in a lot of projects running in particularly
countries of low resource settings like, or lower resource settings like Uganda
where it’s much more reliant on individuals than it is on the system because the
system isn’t particularly strong.” (AAGBI volunteer)
THET’s Principles of Partnership advocate a wide range of stakeholders and multidisciplinary
involvement as it is recognised that health worker movement and overreliance on individuals are
21
risks to long-term sustainability. This may not always be necessary as shown by this partnership.
However, this study has only looked at one partnership, and although highly successful, it may not
be typical in its reliance on a few key individuals. This is an area that would benefit from further
research, for example, developing ToCs for a range of different health partnerships, which includes
those with a wider range of stakeholders and disciplines. This could help determine whether those
with multidisciplinary stakeholders have a larger group of key players, or whether change is still in
fact largely dependent on a few individuals who manage to get things done: as one project designer
said “...just be a bit canny and wise and just learn who are the influential people, and who are going
to take the rest of the team with them.” (AAGBI project designer).
Themes that emerged from the interviews that were not evident in the initial programme proposal
were the pool of long-term volunteers that move from one project and /or organisation to another
and the informal links that are made between different organisations working in the same area.
Advice from one programme designer for other people starting up partnerships was “… find out who
else is working there and work together with them.” This is something that could perhaps be
incorporated as a question into THET’s grant application to assist those embarking on new
partnerships.
Currently THET has little direct involvement with the volunteers that actually work with the overseas
partners to implement the projects. This is potentially a missed opportunity to understand how
change happens as has been illustrated from the data collected in this study. As LTVs often have
experience of various projects and organisations in LMICs their knowledge and experience could be
used to inform project design.
Conclusion
The refined ToC showed that the inputs and intended outcomes proposed in the initial theory for
the SAFE obstetric anaesthesia project were implemented and achieved. Success was greater than
anticipated, and success was largely attributed to the close, long-standing, respectful relationships
between a few key individuals in the partnership along with their motivation and a strong vision for
change. One of the drivers for change appears to be the interest shown in the anaesthetists and a
sense of responsibility to act on the training they have received.
Implications for further study


There is little published literature on the long-term sustainability of train the trainer
programmes and this is an area that would benefit from further research in terms of how
many trained trainers actually go on to train people, if not what are the limiting factors?
The model of a few key individuals needs to be compared with other successful partnerships
to determine whether this is a strength or a one off, lucky example of a successful model.
This could be achieved by developing a ToC for a variety of health partnerships that operate
under different models.
Recommendations
22




THET could consider including a section in the project proposal application relating to other
organisations that are working in the same area as the proposed project and how the
partnership intends to work with them.
THET could engage more with volunteers as they are the people on the ground who see how
change happens so are key people when constructing a theory of change. This could take
the form of seminars with LTVs to assess common problems with programme
implementation and how they actually get things done on the ground.
Health partnerships should consider developing a Toc for programmes when intending to
expand interventions to new contexts, which takes into consideration different relationships
between new partners.
Health partnerships should consider how material resources for providing training can be
sustained by the overseas partner in order to make train the trainer programmes fully
sustainable.
Acknowledgements
I thank all the members of the AAGBI , the AAU and THET who gave their precious time to be
interviewed and participated with such enthusiasm. I also thank Dan Ritman of THET for linking me
up with the members of all organisations and for general support in production of this report, and
also Emily Burn for commenting on a draft of the report.
Conflict of interest
Suzanne Edwards is an independent researcher. This report was funded by THET.
23
References
1.
Van Belle SB, Marchal B, Dubourg D, Kegels G. How to develop a theory-driven evaluation
design? Lessons learned from an adolescent sexual and reproductive health programme in
West Africa. BMC Public Health [Internet]. BioMed Central Ltd; 2010;10(1):741. Available
from: http://www.biomedcentral.com/1471-2458/10/741
2.
Vogel I. Review of the use of “Theory of Change” in International Development. 2012.
3.
Valters C. Theories of Change in International Development: Communication, Learning or
Accountability? [Internet]. 2014. Report No.: ISSN 2051-0926. Available from:
http://www.lse.ac.uk/internationalDevelopment/research/JSRP/downloads/JSRP17.Valters.p
df
4.
Chen H-T, Rossi PH. The theory-driven approach to validity. Eval Program Plann.
1987;10(1):95–103.
5.
Chen H. Issues in constructing program theory. New Dir Progr Eval [Internet].
1990;1990(47):7–18. Available from: http://doi.wiley.com/10.1002/ev.1551
6.
Weiss CH. Theory-Based Evaluation: Past, Present, and Future. 1997;(7).
7.
James C. THEORY OF CHANGE REVIEW A report commissioned by Comic Relief [Internet].
2011. Available from: http://mande.co.uk/blog/wp-content/uploads/2012/03/2012-ComicRelief-Theory-of-Change-Review-FINAL.pdf
8.
Breuer E, De Silva MJ, Fekadu A, Luitel NP, Murhar V, Nakku J, et al. Using workshops to
develop theories of change in five low and middle income countries: lessons from the
programme for improving mental health care (PRIME). Int J Ment Health Syst [Internet].
2014;8(1):15. Available from: http://www.ijmhs.com/content/8/1/15
9.
DeSilva MJ, Breuer E, Lee L, Asher L, Chowdhary N, Lund C, et al. Theory of Change : a theorydriven approach to enhance the Medical Research Council ’ s framework for complex
interventions Theory of Change : a theory-driven approach to enhance the Medical Research
Council ’ s framework for complex interventions. 2014;15(1):1–12.
10.
Hailemariam M, Fekadu A, Selamu M, Alem A, Medhin G, Giorgis TW, et al. Developing a
mental health care plan in a low resource setting: the theory of change approach. BMC
Health Serv Res [Internet]. BMC Health Services Research; 2015;15(1):429. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/26416566
11.
Mason P, Barnes M. Constructing Theories of Change: Methods and Sources. Evaluation.
2007;13(2):151–70.
12.
Anderson A. Community Builder’s Approach to Theory of Change: A Practical Guide to Theory
Development. New York: The Aspen Institute Roundtable on Community Change;
13.
THET. Principles of Partnership [Internet]. 2016 [cited 2016 Feb 27]. Available from:
http://www.thet.org/health-partnership-scheme/resources/principles-of-partnership
24
14.
Edwards S, Ritman D, Burn E, Dekkers N, Baraitser P. Towards a simple typology of
international health partnerships. Global Health [Internet]. Globalization and Health;
2015;11(49):1–7. Available from: http://dx.doi.org/10.1186/s12992-015-0132-x
15.
Ritchie J, Lewis J, McNaughton Nicholls C, Ormiston R, editors. Qualitative Research Practice.
2nd ed. SAGE; 2014.
16.
Dieleman M, Gerretsen B, Wilt GJ Van Der. Health Research Policy and Systems Human
resource management interventions to improve health workers ’ performance in low and
middle income countries : a realist review. Heal Res Policy Syst. 2009;13:1–13.
17.
Hiner CA, Mandel BG, Weaver MR, Bruce D, McLaughlin R, Anderson J. Effectiveness of a
training-of-trainers model in a HIV counseling and testing program in the Caribbean Region.
Hum Resour Health [Internet]. BioMed Central Ltd; 2009 Jan 17 [cited 2016 Jan 24];7(1):11.
Available from: http://www.human-resources-health.com/content/7/1/11
18.
UNICEF. Evaluation of UNICEF learning strategy to strengthen staff competencies for
humanitarian response 2000-2004. 2005.
19.
Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income
countries : A literature review of attraction and retention. BMC Health Serv Res. 2008;10:1–
10.
20.
Tankwanchi A, Ozden C, Vermund S. Physician Emigration from Sub-Saharan Africa to the
United States : Analysis of the 2011 AMA Physician Masterfile. PLOS Med. 2013;10(9).
21.
Baraitser P, Syred J, Spencer-hughes V, Howroyd C, Free C, Holdsworth G. How online sexual
health services could work ; generating theory to support development. BMC Health Serv Res
[Internet]. BMC Health Services Research; 2015;15(540):1–8. Available from:
http://dx.doi.org/10.1186/s12913-015-1200-x
Appendix
Principles of Partnership (see following page)
Full details are available on the THET website http://www.thet.org/health-partnershipscheme/resources/principles-of-partnership
25
Appendix
Principles of Partnership and Hallmarks of Good Practice
1. Strategic
A.
B.
C.
D.
E.
2. Harmonised & Aligned
Partnerships have a clear rationale
with a formal, written document, e.g.
memorandum of understanding
Partnership plans and objectives are
clearly linked to identified needs
Partnerships’ needs assessments and
plans are formally reviewed on a
regular basis
Project activities are prioritised and
planned with measurable outcomes
Exit strategies are developed where
appropriate
A.
B.
C.
D.
E.
Partnership plans reflect national health
priorities or are designed to influence
national priorities
Partnerships’ plans build on an
institution’s strategic health plan
Partnerships are supported by senior
management and colleagues in each
partner institution
Partnerships engage national regulatory,
governance and research bodies with the
potential to support and learn from their
work more broadly or in the longer term
Partnerships collaborate where possible
with other NGOs and INGOs to maximise
effectiveness
3. Effective & Sustainable
4. Respectful & Reciprocal
A.
A.
B.
C.
D.
E.
F.
Partnerships involve a wide range of
stakeholders to ensure continuity and
local ownership
Partnerships explicitly recognise
barriers and challenges to health
systems strengthening, such as health
worker movement and unreliable
supplies
Partnerships are made-up of
interdisciplinary teams to encourage
resilience and adaptability to changing
priorities of the partner’s needs
Projects are based on recognised good
clinical practice and health systems
strengthening principles
Projects are appropriate to the
resources (such as equipment and
staff) available
Projects follow good practice
recommendations for project
management in international
development
B.
C.
D.
E.
26
Partnerships clearly define roles and
equitably share responsibility for project
planning, management and
implementation
Partners collaborate on opportunities
such as research papers and funding bids
Partners listen to and engage with each
other’s needs and ideas
Partners respect each other’s strengths
and weaknesses, and engage frankly and
positively with difficulties in their
relationship and external challenges
All those participating in project
activities comply with the relevant
professional codes for health workers
5. Organised & Accountable
A.
B.
C.
D.
E.
F.
G.
H.
Partnerships have clear, stable governance structures that are not over reliant on individuals
Partnerships engage individuals with the appropriate experience and expertise defining roles
and responsibilities clearly
Partnerships develop and use clear communication channels
Partnerships develop an effective fundraising strategy that draws on multiple sources of
income including financial or in-kind support from both partners
Partnerships develop transparent financial systems with shared accountability for financial
monitoring
Partnerships use procurement processes to minimise costs and cost variability while
maintaining quality of inputs
Partnerships develop effective volunteer management processes and review and update
emergency protocols on a regular basis
Partnerships keep records of significant activities, results, decisions and transactions, and
share them as appropriate
7. Flexible, Resourceful &
Innovative
A.
B.
C.
D.
6. Responsible
A.
Partnerships propose ways to
overcome challenges together that
are mindful of context and the
need for sustainability
Partnerships are flexible in
adapting partnership objectives in
response to changing
circumstances, especially when
there are multiple partners
involved
Partnerships use innovative
methods where appropriate in their
approach to training health
workers and are open to suggestion
from a wide range of sources
Partnerships consider the use of a
wide range of methodologies to
deliver projects, including new
technologies
B.
C.
D.
E.
F.
Partnerships keep up-to-date with
current advice and adhere to
international guidelines and best
practice for international
development organisations
Partnerships are open to admitting
mistakes and reflect & respond
appropriately
Partnerships are able to challenge
each other
All activities are conducted with
honesty and respect for each other
All those participating in project
activities comply with the relevant
professional codes for health workers
Risk associated with project activities
is assessed on an ongoing basis and a
duty of care is provided to all those
participating in project activities
8. Committed to Joint Learning
A.
B.
C.
D.
E.
Partnerships nurture a culture of reflection and learning with monitoring and evaluation
integrated into plans from the outset
Partnerships allocate resources for monitoring, evaluation and learning
Partnerships work together to identify what works, what doesn’t and what can be learned from
this
Partnerships share results and learning widely
Projects incorporate lessons learnt from their work and that of others when planning
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