The ESTHER European Alliance: a decade of hospital partnerships assessed

Author(s) MEZGER Nathalie1.
Affiliation(s) 1Service de Medecine Tropicale et Humnanitaire, Hôpital Cantonal Universitaire de Genève, Genève, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Health Systems
Summary To evaluate a decade of activities, better define the current environment and its future, the ESTHER European Alliance, an initiative based on hospital/institutional partnerships with low resources countries, requested an external, qualitative assessment. Results showed that added value of these partnerships and of the EEA were well perceived. EEA seems in line with the current development cooperation landscape, helping to tackle the health human resources crisis and adapted to face the new health challenges. Nevertheless to better contribute and improve, there was a need to better demonstrate EEA's contribution to the health system strengthening and review its strategy.
Background The ESTHER Alliance (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau - EEA), a French initiative composed currently by 12 European member states (France, Italy, Luxembourg, Spain Germany, Austria, Belgium, Portugal, Greece, Norway, Switzerland, Ireland) and 1 observer (UK), was launched in 2002 to strengthen, through hospital partnerships, the capacities of low income countries to face the HIV/AIDS emergency and related diseases. Each ESTHER national entity is different from each other, but all signed a ministerial declaration of engagement to develop the initiative and are linked by a joint charter of principles.
In 2012 the Alliance members were active in 41 countries and involved in a wide range of training activities including collaboration with civil society organisations. As the last 10 years has seen a change in the worlds health needs and cooperation landscapes, ESTHER evolved and broadened its scope, scale and type of activities to include other health priorities that contribute to meet the Millennium Development Goals 4-5-6 and strengthen health systems to improve health outcomes.
In 2013, an external study was ordered by the Alliance to qualitatively assess the achievements and challenges faced by the EEA over its decade of existence.
Objectives This external qualitative evaluation of the ESTHER initiative, at European and country implementation level, aimed to capture the EEA’s achievements and challenges, draw lessons and clarify the EEA position in the current, evolving, development cooperation and health landscape in order to better define its future. This work was made on request of the EEA.
It focused on identifying the added value of the institutional partnerships for health, on identifying and analyzing the added value that the Alliance brings as a European platform for development cooperation in health, identifying commonalities and challenges for Alliance member bilateral partnership programs, evaluating contributions that partners have made to Health Systems Strengthening (HSS) and presenting future option to move forward.
Methodology Capacity Development International won the EEA international tender after each ESTHER national entity ranked the different candidate’s proposals for this qualitative evaluation.
Two investigators ran it. In all stages of the assessment they included the priority countries that have an active bilateral program (France, Germany, Spain, Italy, Norway and Ireland). Switzerland, Luxembourg, Greece and UK were involved in the first stage of this evaluation. Belgium, Portugal and Austria did not participate.
An extensive review of documents and literature provided by the EEA secretariat, the national coordinating bodies and the technical implementing partners, was performed. It was completed by an international literature review guided by key informants related to development cooperation, health partnerships, capacity development, human resources for health and health system strengthening.
The first stage of interviews focused on the ESTHER model, its achievement, its added value, the challenge and future. They reached the EEA secretariat, 10 northern governments, 13 national coordinating bodies and 2 experts working in the institutional partnerships.
Best practice demonstrating projects were selected by the interviewed national coordinating bodies to be included for the second type of interviews, which focused on the added value of hospital partnerships. Enablers, challenges, lessons learned and contribution to health system strengthening were reviewed. Nine northern implementing partners, 11 southern implementing partners and 3 southern government representatives were interviewed.
Results were analyzed at 4 different levels (added value of institutional partnerships for health, EEA level, National Secretariat level and partnership/project (case studies and lessons learned)) using the OECD/DAC framework (relevance, efficiency, effectiveness, sustainability) to draw out the main themes. Results were synthesised in the perspective of current thinking and EEA objectives and guidelines. Case studies concretely illustrated the evaluation, highlighted innovations, lessons learned and challenges in contributing to HSS.
Limitations were due to the limited time and geographical constraints. Data objective verification was beyond the scope of the study. Best practice projects were selected by the national secretariat and may be subject to bias. Descriptions were dependent on the completeness of information provided.
Results The added value of institutional partnerships (IP) for health based on capacity building and sustainable improvement was clearly perceived. Benefits were: institutional strengthening, responsiveness to needs, ownership, long term building of trust and capacity, peer to peer multidisciplinary exchanges, solidarity, innovation, ability to fund unusual interventions for development cooperation, opportunities to learn how to manage in deprived conditions and cultural sensitivity. IP was felt to go well beyond traditional assistance which is centered on short term filling of capacity gaps and was considered to be a complement to the classical development cooperation.
If hospitals, often neglected in the development, should remain central to ESTHER, inclusion of other organizations or levels was valued.
Concerns expressed the IP potential contribution to the aid fragmentation/proliferation, unintended harms, the creation of pockets of excellence and their real capacity to strengthen the health system.
Recognition, objectification, better definition of the EEA contribution to the HSS were felt to be improved, as the conceptualization of the IP added value to the gaining of knowledge, evidence and ease and the conceptualisation of costs.
The EEA added value was recognized (networking, information sharing), but much of its potential is not fully realized (joint projects, joint working, coordination).
Political mandate and release of resources not straightforward. Weight given to EEA validation and mandate varies. Political commitment was sometimes seen as a mere weight to back-up “ESTHER”, an IP quality brand. Consequently the quest for external funds becomes vital. This would be eased by a better demonstration of the EEA added value beyond members’ programs. The ESTHER diversity, a wealthy fishpond cemented by valuable charter of principles, makes knowledge generation and joint work challenging. If key, knowledge management will have to be balanced as resources are restricted.
In the changing global health agenda ESTHER seems well adapted to address issues such as the non-communicable diseases or the horizontal and integrated approaches. By building capacity, contributing to medical education and continued professional development EEA clearly addresses the human resource crisis.
There is momentum to revisit the EEA vision, strategy and objectives to better adapt to the on-going changes in economy, health and development cooperation.
Conclusion This qualitative study outlines that the EEA, which is based among others on institutional/hospital partnerships, capacity building, local ownership, is needs driven, has long term involvement, respects the Paris Declaration (enshrined in its shared charter of principles), is well aligned with the current thinking and best practices in development cooperation for health. It especially helps in tackling the health human resources crisis.
These principles and ESTHER multidisciplinary identity are clearly of value in the post MDG landscape. Initially focused on the HIV/AIDS crisis, a thematic which was already broadened to include the MDG4-5-6, the EEA has the potential to evolve and contribute to the new emergent health themes.
Added values of IP and of the EEA are well perceived by members, even if it is felt that there is still unveiled potential. The perceived addition of the work in partnerships over other forms of technical cooperation and of the EEA is nevertheless difficult to measure and demonstrate. Creation of enabling, inspiring environments by partnerships does not fully guarantee results. Approaches that address knowledge and capacity gaps through empowerment, leadership by the beneficiary and use of country systems are quite recent and lack rigorous evaluation material to assess their impact. Therefore, efforts should be made to develop material and evaluate processes and projects, but in a light and bearable manner. This could contribute to developing evidence on how to make a quality partnership that brings added value, a matter in which the Alliance could play a role.
Worldwide, little agreement exists on the effective strategy to strengthen the health system, one of the ultimate EEA goals. Operational research could help to clarify how partnership work can contribute to HSS at different levels. The EEA projects/programs diversity is a rich field to work on. This will require the Alliance members to better define and share a common understanding of the HSS.
This knowledge generation would serve EEA to better demonstrate its impact/contribution and increase donors and key stakeholders’ interest. Balance between operational research, monitoring/evaluation and service delivery will have to be found, especially when resources are scarce.
To take advantage of this momentum, clarification and re-definition of the Alliance strategy and structural improvement seem to be needed. A motivating challenge !

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