How to… provide effective technical assistance (2009)

Technical assistance (TA) has long been a substantial component of development assistance in health. Technical assistance is the transfer, adaptation, mobilisation and utilization of services, skills, knowledge and technology. It includes both short and long term personnel from both national and foreign sources, plus training, support equipment, consultancies, study visits, seminars and various forms of linkage. (Development Assistance Committee) In the health arena it implies building the capacity of individuals or institutions to be able to deliver national health objectives. When provided well TA can build sustainable capacity. Yet critics argue that much TA is expensive, often tied to and driven by donors, with too little country ownership and is often inappropriate for the local setting. Technical assistance can be provided in a number of ways: through a long term attachment within an agency; through one-off or repeated short term inputs into a health programme or through engaging in a long-term personal link with a colleague or an institution in a developing country. Links between NHS staff/trusts and counterparts in developing countries have been part of the health development landscape for many years and have accelerated in recent years in part due to more positive signals of support from politicians and health service leaders. The authors have learned a number of lessons over many years of carrying out and commissioning technical assistance. These are distilled below and relate to both those commissioning and those carrying out the task. Whatever the context these lessons will help you deliver effective TA that maximises long term benefits. Ensure you have clear and unambiguous written Terms of Reference (ToR) and a clear understanding of what the client (person(s) commissioning the task) is asking for. If you need clarification from the client then ask. Discussion between the client and consultant at this point is highly beneficial. Agree the outputs of the task and the timeframe. A TA assignment that is in response to local demand, and where the major key stakeholders have been consulted before the ToR are finalised is more likely to succeed. Assess the skills mix that is being asked for and the number of staff and days needed to complete the task. Agree this up front. Develop a clear ToR with unambiguous objectives, timeframe and outputs. Agree in advance what support, if any, will be provided locally and prepare accordingly. If the task cannot be completed in the time available or if you think the scope of work is too broad to be realistic, then negotiate. Resolve any doubts before starting the assignment. Keep records of all written agreements in case things go wrong. Select the right individuals with the right skills set for the task. Strong inter-personal and negotiating skills are vital in making things happen. Remember that the first impression that a consultant makes will be lasting; demonstrating a touch of humility, a willingness to learn from the local setting will make a good start. These soft skills need to be tempered with demonstrating expert knowledge of your subject. Actively spend time listening and understanding why things are done (or not done) as they are. Be supportive, sympathetic and helpful, and work through a cooperative rather than directive approach. Don’t compare the local situation (on a health budget of £5 per capita) to how it is done ‘at home’ (e.g. UK health budget £1500 per capita). Use all opportunities to train local counterparts and build capacity. Be objective, where possible try to validate information from more than one source. Start from the ‘on the ground’ realities of the country. Quickly gain an understanding of local issues of importance that could have an impact on the assignment; for example health spend, staffing patterns, wider social and economic factors, health financing, population, coverage and use of health services. Be aware that institutional politics may influence what you are told and what is possible to change. Make recommendations in the context of the likely resources available. Good TA should lead to outcomes that are feasible and appropriate to the setting. Keep recommendations simple, looking to make small but steady improvements and build on the systems in place as far as possible. Balance what is the ideal with what is the possible given the local budget, willingness to change, and staffing constraints. Recommendations should aim to help overburdened staff do their jobs more effectively and not create more initiatives that cannot be followed through. Demonstrate understanding and empathy for the multiple problems that health workers face. Write in clear, concise language; avoid jargon and repetition; explain technical terms; remember that English is not everyone’s first language. Feedback your findings and recommendations to key local stakeholders before you leave the country and incorporate their feedback in your report. Avoid presenting major surprises in written reports. Include a clear and short summary of findings and recommendations in reports; it may be the only part that many will read. Prioritise recommendations as far as possible: what can be done now, what in the medium-term and what in the longer-term. A short accessible document is more likely to be read and acted upon. If you use PowerPoint presentations then learn to use it effectively; use few words for emphasis and maximise visual representations. Do not be in too much of a hurry to make the changes needed. Build local agreement on the key steps to be taken in the right direction, steadily building up the momentum for change over the long term. Don’t try to move so fast that key local stakeholders are left behind as interested spectators. Local ownership of the process of change is always essential for sustained change. Local managers and staff well understand the many severe systemic challenges in improving health care in low income settings. Foster change champions while in country; successful implementation of recommendations is dependent on local people who believe in them. Take a regular reality check – how are we doing? Seek regular and wide-ranging feedback on performance. Look at what approaches have worked in other countries or settings and why. Regularly ask yourself and others whether you are building and leaving behind greater local capacity. You can learn a great deal from colleagues in developing countries so ensure you are open to this experience. Good consultants actively learn and pick up new ideas and innovative techniques and share them widely. Sometimes the most appropriate TA relationship may be a ‘south to south’ initiative where TA are from the region or continent and may be better able to relate to local needs and requirements. Matching international with local TA can ensure better understanding of the local context. Start from the position of ‘How can we help you?’ and not with predetermined ideas of what you want to do. Explore local perceptions of a link and gauge the level of support and suggestions on what might be achieved. The most successful and sustainable links are the long-term institutional links that have grown over many years. Jointly agree and set out in writing the commitments and responsibilities on both sides of the link programme. Ensure that the learning process is two way. DFID. How to do Technical Cooperation 2006. Available from: http://www.dfid.gov.uk/Documents/publications/tc-how-to-note.pdf. Accessed 13 August 2009. World Health Professions Alliance. A core competency framework for international health consultants 2007. Available from: http://www.whpa.org/pub2007_IHC.pdf. Accessed 13 August 2009.