The value of health partnerships: a practical approach to evidence

Quantitative evaluation of complex health systems

The complexity of health systems, and the ways they are affected by the context in which they operate, make it very difficult to identify long-term changes in health outcomes and to attribute them to particular interventions.^2–4 This is equally true of health systems in the UK and globally, and of development work in general. For this reason, the connection between the immediate outputs of health partnership activities (for example, the number of health workers trained) and long-term changes in health outcomes is non-linear.

Thus, how do we overcome the challenge of measuring impact and ‘value for money’ of health partnerships? Randomized controlled trials (RCTs) are regarded in public health interventions, clinical interventions and many other contexts as the evaluation ‘gold standard’ ⁵ but are incompatible with socially complex service interventions^2,4,6 such as health partnerships. Similarly, economic studies might be used to compare the costs of different interventions to achieve specified impacts, for example in health promotion. However, more rigorous methods of economic evaluation are needed for complex interventions such as capacitybuilding, ⁷ a core part of most health partnerships.

The benefits of qualitative evaluation

Besides their methodological challenges, these kinds of studies require resources that are beyond the capacity of most health partnerships, which are run by volunteers on minimal funding. However, individual health partnerships have a crucial role in evaluating their work using a range of qualitative (and simple quantitative) tools including interviews, audit surveys, training evaluation and feedback, observed changes in practice and knowledge and skills testing.

Such tools can help health partnerships monitor changes in health services. Basildon and Thurrock University Hospital in Essex, UK, and Lumley Government Hospital in Freetown, Sierra Leone, together established the first functioning clinical epilepsy service in Sierra Leone, which in its first year recruited and managed 1500 patients. As described above, it is often difficult to attribute such health service changes to a specific intervention or health improvements to changes in health services. We can, however, look at short-term changes in the skills of developing country health workers and the retention of these skills over time – one of the building blocks of health system strengthening. ⁸

Equally important for development interventions, these qualitative evaluation methods also help health partnerships ‘build, refine, and adapt their interventions in real time’. ² Finally, by helping us understand how change happens in health systems, the data produced by these evaluation methods gets us closer to designing more rigorous impact studies. Without qualitative data, it is very difficult even to decide what indicators to measure and to bridge the gap between outputs and outcomes.

A practical approach

THET supports practical evaluation by encouraging those engaged in health partnerships to make realistic plans and evaluate their work, by providing funding, tools, and advice for forming partnerships, planning and sharing lessons and by enabling health partnerships to share lessons at live events and online. The Health Partnership Scheme, supported by the Department for International Development (DFID), represents not only an increased investment by the British government in health partnerships, but also an important opportunity for THET to continue to gather evidence on what works well and what does not in health partnerships. THET's grounding in practice and our connections with both practitioners and researchers put us in a unique position as a hub for health partnerships research, and we welcome contact from researchers or practitioners exploring these issues.

Declaration

Dan Ritman is funded as part of the Health Partnership Scheme which THET manages for DFID.