Improving the performance of the health service delivery system? Lessons from the Towards Unity for Health projects.

Abstract

The World Health Organization developed the Towards Unity for Health (TUFH) strategy in 2000 for the improvement of health system performance. Twelve projects worldwide were supported to put this strategy into practice. A standard evaluation and monitoring framework was developed on the basis of which project coordinators prepared technical progress reports.
To review the utility and effectiveness of the evaluation criteria recommended by TUFH and their application in four of the original twelve projects.
We reviewed status reports provided by European project coordinators and developed a standardized reporting template to extract information using original TUFH evaluation criteria.
The original TUFH evaluation framework is very comprehensive and has only partly been followed by the field projects. The evaluation strategies employed by the projects were insufficient to demonstrate the connections between the intervention and the desired process improvements, and few of the evaluation measures address outcomes.
The evaluation strategies employed by the projects are limited in allowing us to associate the intervention with the desired process improvements. Few measures address outcomes. The evaluation of complex community interventions poses many challenges, however, tools are available to assess impact on structures and process, and selected outcome indicators may be identified to monitor progress in future projects.
Based on the review of evaluation status of the TUFH projects and resources available we recommend moving away from uniform evaluation and towards monitoring minimal, context-specific performance indicators criteria.

Full text

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ORIGINAL RESEARCH PAPER
Improving the Performance of the Health Service
Delivery System? Lessons from the Towards
Unity for Health Projects
OLIVER GROENE1& LUIS A. BRANDA2
1Technical Officer Quality of Health Systems and Services, WHO Regional
Office for Europe, Copenhagen and
University, Hamilton, Canada
2Professor Emeritus, McMaster
ABSTRACT
for Health (TUFH) strategy in 2000 for the improvement of health system performance.
Twelve projects worldwide were supported to put this strategy into practice. A standard
evaluation and monitoring framework was developed on the basis of which project
coordinators prepared technical progress reports.
Objectives: To review the utility and effectiveness of the evaluation criteria recommended
by TUFH and their application in four of the original twelve projects.
Methods: We reviewed status reports provided by European project coordinators and
developed a standardized reporting template to extract information using original TUFH
evaluation criteria.
Results: The original TUFH evaluation framework is very comprehensive and has only
partly been followed by the field projects. The evaluation strategies employed by the
projects were insufficient to demonstrate the connections between the intervention and the
desired process improvements, and few of the evaluation measures address outcomes.
Discussion: The evaluation strategies employed by the projects are limited in allowing us
to associate the intervention with the desired process improvements. Few measures
address outcomes. The evaluation of complex community interventions poses many
challenges, however, tools are available to assess impact on structures and process, and
selected outcome indicators may be identified to monitor progress in future projects.
Conclusion: Based on the review of evaluation status of the TUFH projects and resources
available we recommend moving away from uniform evaluation and towards monitoring
minimal, context-specific performance indicators criteria.
Context: The World Health Organization developed the Towards Unity
KEYWORDSTowards Unity for Health framework, evaluation strategies, monitoring
performance.
Author for correspondence: Mr Oliver Groene, MA, MPH, Technical Officer Quality of Health
Systems and Services, Marc Aureli 22-36, E - 08006 Barcelona. Tel: þ34 93 241 8270.
Fax: þ34 93 241 8271. E-mail: ogr@es.euro.who.int
Education for Health,
Vol. 19, No. 3, November 2006, 298–307
Education for Health ISSN 1357-6283 print/ISSN 1469-5804 online ? 2006 Taylor & Francis
http://www.tandf.co.uk/journals
DOI: 10.1080/13576280600937861

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Context: Towards Unity for Health
In 2000 the World Health Organization launched the initiative ‘‘Towards Unity
for Health’’ (TUFH) to study and promote efforts to foster unity of service
provision for a population’s health needs (illustrated graphically in Figure 1).
The goal of this initiative was to improve the performance of the health service
delivery system and make it more relevant to the needs of the population. This
would be achieved by raising awareness among the various actors who function
in the health services delivery system and who possess a need to create
productive partnerships through the facilitation and coordination of interven-
tions oriented at both individual and community health needs of a given
population. The conceptual model of TUFH is that this strategy of building
partnerships among key stakeholders in a specified population – policy-makers,
health managers, health professionals, academic institutions and communities –
will lead to improved coordination, relevance and performance (TUFH
Newsletter, 2000).
Twelve projects were selected globally to implement the TUFH strategy. A
standard evaluation and monitoring framework was developed and provided to
the project coordinators for use in preparing technical progress reports. This
framework addresses four perspectives or clusters (TUFH, 1999): It is based on
Figure 1. The TUFH framework.
Lessons from the TUFH projects299

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the strong assumption that new models and patterns of services result in better
partnerships among stakeholders, which then result in better integration of
services. This process in turn, then impacts the activities of health professionals
and results in better health systems performance (Table 1). This framework
is developed in greater depth in a working paper prepared by WHO
(Boelen, 2000).
.
The first cluster addresses innovative patterns of services for integrating
medicine and public health (definition of reference population and
territoriality, description of organizational model for integration (range,
linkage) and use of comprehensive health information management);
The second cluster refers to the implications for health professionals
(practical impact on roles and rewards, and the degree to which educational
institutions and programmes are social accountable);
The third cluster addresses partnership functioning (the partners involved
and the quality of partnership);
The fourth cluster relates to the evidence of impact (the effects on quality,
equity, relevance and cost-effectiveness and diffusion of the idea).
.
.
.
This article reviews the extent to which four of the twelve TUFH field projects
followed the suggested evaluation framework.
Methods
Our review of existing TUFH projects was based on biannual reports prepared
by the TUFH project coordinators and submitted to WHO. Reports described
the progress made in the projects, difficulties experienced and the results
obtained. The following material was available at the time of the review
(Table 2).
This review is limited to the four European TUFH projects carried out in the
Czech Republic, Italy, Spain, and the Netherlands (TUFH, 2001, 2002).
Table 1. Evaluating health system impact: structure, process and outcome
Partnerships Health system processesHealth system results
(a) Productivity of partnership"
(a) Coordination and
integration "
(b) Fragmentation #
Causality
(a) Performance"
(b) Sustainability of partnerships"
————————————"
(b) Relevance"
The more productive and sustainable the partnership is (a) the better is the coordination
and integration of health care services, (b) the smaller is the fragmentation of health
care services, and (c) the better is the performance and relevance of health care services.
———————————— "
300O. Groene & L. A. Branda

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Rationale for this limitation is that there was a direct communication between
the WHO Regional Office for Europe and European project leaders, the latest
reports were available from the European projects; time and budget did not
allow to extend the review to include all TUFH projects. We developed a
standardized template to extract data from the reports for each of the four
clusters from the original TUFH evaluation framework: integrating medicine
and public health, implications for health professionals, partnership functioning
and evidence of impact.
Results
Review of the TUFH projects
TUFH projects from the Czech Republic, the Netherlands, Italy and Spain
were included in the review. Reports were assessed for issues addressed in the
TUFH evaluation and monitoring framework.
The TUFH projects reported here were very diverse, both in territory and
population served, as well as in their focus on diseases, risk factors and
determinants of disease. The review found that the process evaluations of the
projects were based on rather loose criteria such as meetings planned
and attended. The outcome evaluations were drawn on repeated measure-
ments, questionnaires and national statistics. Details of the projects them-
selves can be found in the field reports and the paper by Lippeveld and
Glasser (2002).
The results of this review on evaluation strategies are listed graphically in
Table 3 (Table 3).
The results demonstrate that not all the issues addressed in the TUFH
evaluation framework were actually described comprehensively in the reports.
For example, beyond identifying the target of the community intervention it
was very difficult to extract from the reports what constitutes an innovative
approach to combining public health and medicine – most projects appeared to
follow classical public health interventions. In addition, there was little
information to address the implications of the intervention for health
professionals. While there was some mention of the effectiveness of social
Table 2. TUFH reports available for the review
Date TUFH report available for:
July 2001 USA, Canada, Czech Republic, Indonesia, Italy, Kenya, Morocco,
Nigeria
Spain, Canada, Czech Republic, Netherlands, Spain, USA, Kenya
Netherlands, Italy, Spain
December 2001
October 2002
Lessons from the TUFH projects 301

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Table 3. Overview on evaluation of European TUFH projects
Country (source)
Integrating medicine
and public health
Implications for health
professionals
Partnership assessment
Evidence of impact
Czech Republic
(progress report,
December 2001)
Project: Needs
assessment of
community care
Territory: Towns and
surrounding areas of
Kladno and Slavkov
Identifying patients’
comprehensive health
and social care needs
Support by and
participation of
stakeholders, MoH
Design: Interviews,
national statistics
Results: Awareness
raising of health & social care
cooperation
Italy
(progress report, July
2002)
Project: 1. integrated
care, 2. zoonosiscontrol and 3. health
impact assessment
Territory: Ragusa
region, 300.000 people
1. Overcoming the
mental gap between
primary and
secondary care
2. Need to set financial
incentives
3. Improve use social
marketing tools
Support and
participation of
stakeholders
Design: questionnaires,
meetings
Results: 1. planning of
system to evaluate
integrated care, 2.
monitoring number of
infections prevented,
3. production of flow
chart
The Netherlands1
(progress report
September 2002)
Project: reduction of
cardiovascular disease
Territory: Hartslag
Limburg region,
180,000 people, high
risk group of
2,700 people
Consider to accept
community members
in health projects
Use social marketing to
address health issues
Participation in
meetings, assessment
of follow up based on
minutes, securing
funding
Design: Baseline survey,
repeated
measurement,
randomized control
trial (in high-risk
group)
Results: Fat reduction in
community group
(continued overleaf)
302O. Groene & L. A. Branda