Improving the performance of the health service delivery system? Lessons from the towards unity for health projects

Context: 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. 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.