At THET we believe that health partnerships run better health projects than individual institutions or experts who arrive with plans fully formed. It’s certainly plausible that the trust, understanding and resources embodied in a strong health partnership lead to effective, sustainable health workforce or health systems strengthening. But is it true? THET commissioned Suzanne Edwards to look at some of the evidence.
The bulk of health partnership monitoring, evaluation and research has been directed at the projects themselves, exploring the activities delivered and the short and, sometimes, long-term results for health workers and health institutions. It does not do enough to unpack the partnership’s role in the achievement or in failings at project level. Did existing relationships help a partnership to design and deliver a strong project, and if so, how? To explore that question, THET commissioned researcher Suzanne Edwards to analyse a health partnership in detail. She looked at why we believe partnerships run better projects, and whether one health partnership really demonstrates that. You can read her full report here.
The health partnership
The subject of the research was the health partnership between the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Association of Anaesthetists of Uganda (AAU), with a focus on its health workforce strengthening project funded by the Health Partnership Scheme, 2012–2014. The project trained non-physician Anaesthetic Officers (AOs) in SAFE Obstetric Anaesthesia. We wanted a strong partnership as the subject of the study, and in a mapping exercise we found that AAGBI–AAU had strong evidence for seven out of the eight Principles of Partnership.
The researcher developed two theories of change, diagrams showing how one input or change leads to another. The first one was constructed using the information in AAGBI–AAU’s funding proposal. It sets out the partners’ expectations and assumptions about how the project inputs, such as training, would lead to outputs, such as improved knowledge, and then outcomes, such as better anaesthetic service provision (see Figure 2, Initial theory of change map, page 8 in the report).
The second theory of change was constructed through analysis of the partnership’s narrative reports, interviews with stakeholders (THET, AAGBI, AAU), and a focus group discussion with staff from THET. Stakeholders talked in detail about what had actually happened – the challenges, the crucial contributions, the roles of individuals and institutions – and their refined understand of the context. These points, and their broader perspective on the partnership, are reflected in the revised diagram (see Figure 3, Refined theory of change map, page 13 in the report).
The refined theory of change is complex but it brings out intangible dynamics between the partners and within the training environment that enabled achievement of the project’s tangible objectives. In particular, it highlights two factors that have been crucial in the AAGBI–AAU project, and which are relatively neglected in writing about health partnerships:
Firstly, individuals are crucial. For THET, health partnerships are primarily relationships between institutions, which benefit from institutional longevity and resources. THET does recognise the role of key individuals (Principle of Partnership 5b) in bringing about and sustaining change, and this research has highlighted it. Success in both project and partnership depended on the enthusiasm and dedication of a few people with the status to influence decision-making. As one AAGBI volunteer suggested, when a health system is unable to offer the support its health workers need, individuals may step in.
Secondly, improved motivation was critical for building project momentum and driving forward change. The project activities and relationships helped Anaesthetic Officers (AOs) develop a sense of belonging and respect; they felt appreciated by colleagues, managers and the community; they were motivated by the project’s success; overall, the AOs developed a sense of empowerment to make changes in their hospitals and physician anaesthetists became committed to deliver training. This theme can be undervalued in accounts of health partnership work that focus on clinical and other skills.
The study also helps THET reconsider our advice (Principle of Partnership 1a) that partnerships have a memorandum of understanding. The AAGBI–AAU partnership did not have an MoU for a long time yet it was a very active collaboration. Other health partnerships have found that an MoU clarified aims, roles and responsibilities, but this research makes clear that the absence of an MoU is not necessarily detrimental to partnership development.
The partners also made clear that although the project would have been impossible without the HPS grant, it was enabling rather than motivating. The partnership was ready to collaborate and it applied for funding to strengthen their work, rather than creating a project or partnership to exploit funding on offer. For THET, this emphasises a point we recognise: the importance of both partners’ readiness to undertake a project (state of infrastructure, leadership, and security) as well as their willingness (ownership, commitment) to participate.
Limitations and next steps
The findings add to our understanding of the partnership approach and potentially strengthen THET’s ability to identify and support high quality health partnerships.
The main limitation of the study is that it is a sample of just one health partnership. To make the findings more generalisable, we need to do similar research with other health partnerships, for example:
Please see the full report for more details.
Note on training of trainers resources
The AAGBI–AUU project created a cohort of Ugandan trainers. Training of trainers (ToT) is a common thread in health partnership work. We believe it can underpin sustainability in skills development, reduce dependence on external trainers, and provide benefits such as staff retention and empowerment of certain cadres. However, there is limited evidence of the effectiveness of ToT approaches in practice, and the barriers and enablers of a successful ToT programme. To begin addressing this, we have recently published a paper and held a webinar on ToT in health partnerships, both available now.