Chapter 1.1 An introduction to Links,the philosophy on which they arebased and the political context withinwhich Links work.
Chapter 1.2 Who benefits from Links,how the work of Links contributes toHealth System strengthening andwhat types of work Links have beenengaged in.
12
SECTION 1.Overview of InternationalHealth Links.
13
In this Chapter:• What is a Link?
• A short historyof Links
• Underpinningprinciples of Links
• Different modelsof Links
An International Health Link(a Link) is a partnership between aUK and a Developing Country (DC)health organisation. This Chapterhelps you to gain an understandingof what Links are, what theirpurpose is and the principles onwhich they are based.
14
1.1 An introductionto Links
2Links may be of different scales and sizes and many develop from smaller partnerships and personal collaborations.Health Links are one of many types of organisational Links between UK and DCs. An increasing number ofcommunities, schools, faith-based organisations, local authorities, youth groups and others in the UK have establishedpartnerships with counterparts in DCs. Health Links may fit in within a wider community Link. Such Links often involvethe diaspora in the UK from the countries with which they are linked thus adding to greater social cohesion. Differentkinds of Links come together in the UK under the umbrella of the organisation BUILD. (www.build-online.org.uk)
3The partners involved at the UK end may be NHS Trusts, Foundation Trusts, Primary Care Trusts (PCTs), GP practices,Universities, professional bodies, clinical networks, etc. At the DC end, partners may be hospitals, health centres,District Health Offices, training schools, universities, professional bodies, etc. If necessary, Links may also be formedbetween more than two partner organisations.
1.1
15
1.1 An introductionto Links
What is a Link?Links are all about peopleworking together to share ideas,knowledge and friendship toimprove health care. By doingthis within an organisationalagreement, Links have thepotential to be strategic and longterm, better able to inspirechange. Some established Linkshave shown that they are ableto bring about importantimprovements in health care.
A Link2 is a formalised voluntarypartnership between counterparthealth organisations3 in the UKand a Developing Country (DC).The primary purpose of Links isto build the capacity of the DCorganisation, but there are alsoimportant secondary benefits forthe UK health sector. The activitiesthat Links support can be verybroad and range from trainingand capacity-building for staff,providing practical skills,continuing professionaldevelopment, supportingimprovements within DCorganisations, facilitating research,and curriculum development etc.
Who gains? A well-managed Linkcan bring about importantchanges for both the DC and theUK organisation. DCs can buildcapacity and motivate their staffby drawing on the UK partner’sexpertise and technical assistance,according to their own priorities.
The UK organisation also hasa great deal to gain; it has theopportunity to develop its staff,it gives them ideas for serviceimprovements and exposes themto international health issues.It is also an opportunity for bothorganisations to engage in jointresearch.
In an ideal Link, both organisationswill benefit greatly in differentways. The main currency of theLink is the professional expertiseand human resources availablewithin both organisations.
How does it work? After initialset-up and joint planning, the workof a Link typically involves some ofthe following activities:
• Reciprocal visits to deliveragreed training
• Support through mentoring,equipment and trainingmaterials
• Technical assistance on thedevelopment of services
• Monitoring and evaluating thework to plan future activitiesand scale up support
A short history of LinksThe wider political agendaWhile THET has been supportingand working with Health Links forover ten years, it is only since2004 that Health Links have beenon the wider political agenda.
The Commission for Africa (2004)and the Gleneagles G8 Summit(2005) put health and health carein Africa at the centre of theiragenda. The WHO report, HumanResources for Health (2006) tooka lead in highlighting the severeshortage of human resources forhealth in developing countries,bringing to the fore many of theissues that had confronted thoseworking in the health sector indeveloping countries.
DC Governments are increasinglyseeing Links as an opportunity totap in to the expertise availablewithin the UK. Many doctors fromDCs have completed some part oftheir medical training in the UKand look to the UK for guidanceand support. THET has developedcodes of conduct and Memorandaof Understanding (MoU) with theMoH of Uganda and Ghana, amongothers. The many diasporacommunities in UK also make animportant contribution tosupporting the development oftheir own countries and this canbe enhanced by Health Links.
DID YOU KNOW?
There is a direct relationshipbetween the ratio of healthworkers to population andthe survival of women duringchildbirth and children ininfancy. As the number ofhealth workers declines,survival declinesproportionately. If donorfunds are to have any impactand the MillenniumDevelopment Goals are to beachieved, the right number ofhealth workers with the rightskills need to be in place.
The 2006 WHO report statedthat 57 countries, most ofthem in Africa and Asia,faced a severe workforcecrisis, with Sub-SaharanAfrica facing the greatestchallenges. Africa has 11% ofthe world’s population, 24%of the global disease burdenand only 3% of the healthworkers to deal with it. Evenwithin countries inequalitiesexist, with rural areas findingit harder to attract healthworkers than the urbancentres.
Working together for Health,WHO report 2006
2005THET published the first LinksManual which raised awarenessaround what health partnershipscould offer. THET’s role insupporting Links was furtherencouraged with a staffsecondment from the Departmentof Health (2005-2007) andfunding from the Departmentof Health and Department forInternational Development.
It was becoming increasingly clearthat it was not possible to deliverthe Millennium Development Goals– the bedrock of internationaldevelopment policy aims – withouta significant increase in capacity,skills and training in thedeveloping countries; all areas inwhich Links can play an importantrole.
2006Since 2006 the devolvedGovernments of Scotland andWales have also been increasinglysupportive of international health.The Wales for Africa Group, whichreceives funding from the WelshAssembly Government, has beensupporting Links since 2006 andstrongly believes that sharingskills, experiences and resourceshelps communities in Africa andWales. The Scottish Governmentincludes support for Links as partof its agreements with AfricanGovernments including Malawiand Zambia to help improvehealth care.
2007/2008The UK Government respondedpositively to the Crisp Report(2007) which looked at how UKhealth expertise could be used tohelp improve health in developingcountries. It championed the roleof International Health Links andof THET. The Government agreedto support the development ofLinks via a new grants schemeand information centre relatingto Links. It agreed to pay pensioncontributions to those doinghealth work overseas for extendedperiods of time. Links were alsofeatured favourably in theGovernment’s wider Global HealthStrategy, “Health is Global”(September 2008).
FIND OUT MORE
• About THET – Appendix 1
• Our Common Interest,report published by theCommission for Africa(2005)
• Working together forHealth, WHO report 2006,available from www.who.int
• Global Health Partnerships,Lord Crisp (2007)Significant referenceto THET is made
• Government response tothe Crisp report (2008)
• Health is Global: A UKGovernment Strategy2008-13, Departmentof Health (2008)
KEY TERMS
Millennium DevelopmentGoals (MDGs): are a set ofgoals to be achieved by 2015that respond to the world'smain developmentchallenges. The MDGs aredrawn from the actions andtargets contained in theMillennium Declaration thatwas adopted by 189 nationsand signed by 147 heads ofstate and governmentsduring the UN MillenniumSummit in September 2000.
1.1 An introductionto Links
16
G
a
/
Underpinning principlesof LinksTHET advocates a set of principlesto underpin the work of Links,which may differentiate themfrom other types of twinningarrangements or aid initiatives.The underpinning principles are:
• The primary focus of Links ison capacity-building and staffdevelopment through targetedtraining. While occasionallyLinks may provide additionalsupport, such as equipment,books or direct service delivery,this is not their primary remit.
• Links specifically respond tothe requests (explored throughcareful dialogue) and worktowards the goals of theorganisation in the DC withina partnership.
• Links are organisationallysupported, or formalisedthrough a network, enablingthem to be interprofessional,plan for the long term, workmore effectively and be lessvulnerable to staff turnover.While individuals play animportant role, a Link is acollective effort.
• Links are interprofessional andusually interdisciplinary, andable to draw on a range ofexpertise from the UK partnerorganisations. This allows theLink to be flexible and respondto changing priorities of the DCLink partner.
• Links are long term.‘Strengthening health systems’is a long term goal and changeis often slow. Links take time todevelop, are based on trust andunderstanding and should be an
enduring collaboration betweenpartners, not limited to shortterm gains.
• The work of Links is alignedwith national strategies andorganisational priorities anddoes not aim to create parallelsystems or services.
• Links are a means to an end(strengthening alreadyestablished health systems),rather than an end inthemselves. The added valueof a Link should regularly bereviewed through evaluation.
REMEMBER
The UK partner muststart with the question: Whatare your priorities and whatdo you want us to do? And,having explored this in acareful dialogue, draw onexpertise from across theirorganisation to be able torespond to this need.
Different models of LinksThere is no pre-defined modelfor a Link, as each one may differslightly. What they are trying toachieve and who is engaged mayalso vary from Link to Link.
A simple Link will be a partner-to-partner relationship. Theseusually work best if they arebetween similar organisations.The partners may be health careproviders such as hospitals,primary health care providers,health training schools ornetworks of professionals.
In some cases the Link maybe more complex: a core Linkdrawing on support from other
organisations or a recognisedtripartite relationship. Whetherthe partners are a singleorganisation or a more complexcoalition, Links should arisethrough a specific need or requestfrom the DC, and be matched to aUK organisation with a similaroutlook.
CHAPTER CHECKLIST
} Links are partnershipsbetween UK and DCorganisations with theprimary aims of sharingknowledge andinformation to improvehealth services.
} Links have recentlygained momentum andincreasing governmentsupport.
} To be effective a Linkmust be well planned andbe underpinned by anumber of key principlesincluding a focus onbuilding capacity, beingresponsive andmultidisciplinary.
1.1 An introductionto Links
17
!
1.1
}
1.1 An introductionto Links
18
DID YOU KNOW?
Partnerships and International Development
Health Links are one element of international development partnerships; others include schooltwinning arrangements, higher education and science/technology partnerships. They are generallyset up in recognition that there are mutual benefits to both sides of the Link or partnership.
The history of international development has not always been characterised by such balance.Indeed, many of the terms traditionally used to describe relations between two parties reinforcethe imbalance – ‘donors’ and ‘recipients’, for example. ‘Aid’ suggests a one-way relationship, andis now normally used only in the context of humanitarian or emergency assistance. ‘Officialdevelopment assistance’ is standard terminology; ‘economic co-operation’ is also used.
International development as we understand it really began in the late 1950s, as the colonialpowers provided financial and technical support to their former colonies as they gainedindependence. Much of this was used to maintain the organisations set up during the colonialperiod – schools, hospitals and roads. This ‘capital aid’ was part of a package which includedtechnical assistance, and in the 1960s and 1970s favoured the provision of personnel from the UK(judges, doctors, teachers etc.) as local capacity was being developed.
While there was some effort made in the 1970s and 1980s to ensure that ODA supported thedevelopment of livelihoods and a better quality of life for ordinary people (see, for example, the1973 Government White Paper ‘More Help for the Poorest’), international relations – including aidand trade – were largely driven by the dynamics of the Cold War. The over-riding consideration fordonors was not about recipient Government efforts to reduce poverty, but on which side of theideological divide they stood.
This largely changed with the fall of the Berlin Wall. European countries in the former EasternBloc were told that they would be welcome in the European Union, but only on condition that theycarried out political and economic reforms which would lead to them becoming more open andpluralistic societies. In the early 1990s, these considerations were increasingly applied also torelationships with developing countries, with support increasingly dependent on their record onissues like governance, human rights and social inclusion.
At the same time, there was an increasing recognition that development assistance should supportpolicies and programmes developed in-country, rather than seek to drive them. The late 1990s sawthe development of ‘Poverty Reduction Strategy Papers’ produced (in theory, and increasingly inpractice) in developing countries. The willingness of the international community to supportcountry-driven programmes has been accompanied – at least for those developing countriesjudged to have sound policies – by a continuing shift away from project assistance towards sector-wide approaches and general budget support.
In September 2000, 147 Heads of Government signed up to the Millennium Development Goalsin New York. They were aspirational and non-ideological, with a strong focus on basic health andprimary education outcomes. But it has become increasingly clear, as highlighted in the 2005Commission for Africa Report, ‘Our Common Interest’, that it will not be possible to deliver thoseoutcomes by 2015 without a significant increase in capacity, skills and training.
Links can play an important role in the development of organisational capacity and the building ofhealth and education systems in developing countries; and at the same time, as everyone involvedin a Link will attest, the learning is very much of mutual benefit. Health Links are a manifestationof true partnership – a partnership from which everyone gains and in the process makes the world,in however small a way, a better place.
Photograph (right): Hannah Maule-ffinch, Uganda
G
Links can play an importantrole in the development oforganisational capacity and thebuilding of health and educationsystems in developing countries.
1.2Why Link?
20
This Chapter looks at who benefitsfrom Links, what support Linkshave given and asks whether Linksreally have an impact.
The primary objective of the Linkshould be to improve healthservices for the poorest people indeveloping countries, but both UKand DC organisations involved inLinks often report significantbenefits.
In this Chapter:• Who benefits?
• What can Links do?
• Examples of howLinks can work
1.2Why Link?
21
Who benefits?
“You are making anapparent difference in ourhealth care delivery at thereferral hospital. Thank youall members of theSouthern Ethiopia GwentHealth Link”
Dr Yifru, HawassaUniversity, Health SciencesCollege, Ethiopia
If a Link is well planned andmanaged, it can bring aboutimportant changes for theindividuals involved in the Link,the organisations within whichthey work, and ultimately thepatients that they serve. ManyLinks report significant benefitsand improvements in services.At the moment much of this isbased on anecdotal reports, butas Links start to integrate morerigorous evaluation into theirwork, the evidence base willbecome stronger and moreclearly documented.
The following table is based onone piece of research carried outby King's College Hospital whichlooked at the benefits to the UKorganisation of being involved ina Link.
Main benefits for the NHS
Personal
• Personal satisfaction/inspiration
• Learning about differentcultures
• Appreciation of NHS/senseof perspective
Professional
• Understanding of patients fromrelevant part of the world
• Hones clinical skills, andrefreshes basic skills withoutdependence on high-techmachinery
• Familiarisation with pathologiesthat are less common in UK(but may grow there)
Non-Clinical professional skills
• Improved teaching skills
• Development of resourcefulness
• Greater awareness of how toavoid waste and work with fewresources
• Team skills enhanced byinterdisciplinary team effort
Organisational
• Link can enhance reputation
• Good for job satisfaction,retention and motivation ofcommitted staff
• Good for recruitment ofcommitted NHS staff
Universities
• Can assist global cachet
• Good framework for studentelectives
• Helps recruit committedstudents
Personal, professional and organisational rationale for Links(UK persepective)
Disadvantages for the NHS
• Risk of exhaustion, stress,from overseas Link activity
• Neglect of family whileengaged in Link work on topof normal demands
• Some annual leave used up ifno study leave allowed. Higherrisk of accident or securityproblem in some cases
• Problems of arranging coverand imposing on others whenabsent on Link business
• Finding alternative cover whenpeople are away onLink business
• Opportunity costs; time andresources expended on Linksare not available at the sametime for other expressions ofCorporate Responsibility ororganisational improvement
• Need to manage security risks
• Distraction from financialimperatives of the ResearchAssessment Exercise
1.1
What can Links do?
Can Links contribute to healthsystem strengthening in DCs?
The effectiveness of any healthsystem is determined by theinteraction of many influencingfactors and Links can contributeto some of these influentialfactors. If the Link is well plannedand responds to specific needs,
this contribution will be importantbut is likely to be modest.
The resources available to mostLinks are very small whencompared to the large budgetsavailable to other global initiativesand international partnershipssuch as GAVI, PEPFAR and UNICEF.The range of expertise available ina UK organisation will be wide, but
the time available to contributewill be limited for most people.
The following diagram illustratessome of the factors which are atplay in determining how well ahealth system functions; thearrows illustrate some of the areaswhere Links have shown they canplay a role.
1.2Why Link?
22
HealthWorkforcenumbersskillbase
&motivation
r
Public Healthand diseaseprevention
Managementand
InformationSystems
FactorsaffectingHealthSystems
Leadership andGovernancewith strategic
policyframeworks
Health Financing% of GDPto health &donor support
DiseasePrevalenceAcute/chronic
Medical productsDrug availabilityand distribition
systems
Infastructurebuildings,
equipment, accessto services
Socio-economicfactorseducation,nutrition,employment
r
r rr
r
r
Factors affecting Health Systems(and where Links can play a role)
UK Link partners need to be awareof the many different factors atplay. There is sometimes anidealistic notion among those newto international work that there isa quick and easy solution and theLink alone will be able to turnthings around.
This is unlikely to happen and mayresult in a loss of enthusiasm whenchange is slow to happen. The Linkcan provide an importantcontribution but this will mostoften be the case when the otherfactors at play are also conduciveto this change. On the other hand,persistence and sounddevelopment of the Link can payoff to the point that, in somecases, the Link eventuallybecomes a vehicle for moreextensive programmes of workbacked by funding agencies.
REMEMBER!
Change is about evolutionnot revolution. There issometimes an unrealisticnotion amongst those new tointernational work that thereis a quick and easy solution.In reality change is slow tohappen. See the case studyon p30.
Examples of what Links cansupportLinks have been involved in anextremely broad range of issues.Much of the work of Links fallsunder the category of capacity-building: developing the skills ofhealth workers, organisationalstructures, resources andenthusiasm of overseas colleaguesto improve health services. Thissection gives some examples ofsome of the things that Links havebeen asked to support.
FIND OUT MORE
For examples of what Linkshave supported refer to theexamples on THET's website.
CHAPTER CHECKLIST
} If well planned, Links areable to bring aboutimportant benefits to bothUK and DC partners. It isimportant for Links tothoroughly documentthese impacts.
} While the contributionthat Links can make toimproving health servicesis only modest, thepartnership nature of thework makes it valuable.
} Links are able to supporta variety of differentareas, many of whichcome under the broadheading of capacity-building. Links shouldalways respond to theexpressed needs of theDC partner.
1.2Why Link?
23
/
!
}
1.2
1.2Why Link?
24
Potential areas that Links can support
Training thetrainers
Undergrad/Postgradtraining
Introducingnew
technology
Developmentof systems
and protocols
Curriculumdevelopment
Potentialareas thatLinks cansupport
ContinuingProfessionalDevelopmentand in-service
training
Strengtheningexistingservices
Distancelearning
Equipmentprovision
Collaborativeresearchincluding
clinical auditthrough active communication
between partners
Photograph (right): Lihee Avidan, Malawi
Change is about evolutionnot revolution. Links arelong-term partnerships.
