The document discusses transformative evaluation approaches for global health interventions, emphasizing the importance of evaluative thinking in assessing programs and their effectiveness. It critiques traditional evaluation methods, outlines the complexities of health interventions, and highlights the need for adaptive approaches to evaluation that account for evolving contexts and stakeholder involvement. Key recommendations include focusing on sustainability, clarity in partnerships, and aligning evaluation metrics with desired health outcomes.

1. Towards a Transformative View of
Evaluation: Evaluating Global Health
Interventions
Presentation at the International Food Policy Research
Institute
Sanjeev Sridharan
The Evaluation Centre for Complex Health Interventions
University of Toronto &
St. Michael‟s Hospital
November 19, 2013

2. How do we
make
evaluations
matter?
Two
Examples
What is
evaluation?
Evaluating
Research:
Pathways of
Influence
Summing up

3. What is evaluation? A useful but
perhaps incomplete definition
• Evaluation is defined both as a means of
assessing performance and to identify
alternative ways to deliver
• “evaluation is the systematic collection and
analysis of evidence on the outcomes of
programs to make judgments about their
relevance, performance and alternative ways
to deliver them or to achieve the same results.”
…..what role can evaluation/ evaluative thinking
play in navigating interventions?
3

4. Purpose of evaluation (Mark,
Henry and Julnes, 2000
• Assessing merit and worth
• Causal questions, RCT, observational studies
• Programme and organizational improvement
o Formative evaluation
• Oversight and compliance
• Knowledge development
o Neglected purpose of many evaluations
4

5. An Example: Primary Prevention
Have a Heart Paisley

6. Features of complex interventions (Pawson et al., 2004)







The intervention is a theory or theories
The intervention involves the actions of people.
The intervention consists of a chain of steps
These chains of steps or processes are often not
linear, and involve negotiation and feedback at
each stage.
Interventions are embedded in social systems and
how they work is shaped by this context.
Interventions are prone to modification as they are
implemented.
Interventions are open systems and change
through learning as stakeholders come to
understand them.

7. System Dynamic Approaches (Sterman, 2006)
•
•
•
•
•
•
Constantly changing;
Governed by feedback;
Non-linear, History-dependent;
Adaptive and evolving;
Characterized by trade-offs;
Policy resistance: “The result is policy
resistance, the tendency for interventions
to be defeated by the system‟s response
to the intervention itself.”

8. ‚Solutions‛ Can Also Create New Problems
Policy resistance is the tendency for interventions to be delayed, diluted, or defeated by the
response of the system to the intervention itself.
-- Meadows, Richardson, Bruckman
Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982.
Merton RK. The unanticipated consequences of purposive social action. American Sociological Review 1936;1936:894-904.
Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.

9. System-as-Cause
Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.
Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999.
Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>.
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

10. So why are evaluations so
often not very useful?

11. UN Office of the Internal Oversight
Services, 2008
• A Critique of Results-Based Management (2008).
• “Results-based management at the United Nations
has been an administrative chore of little value to
accountability and decision-making.”

12. The UN Critique of performance
management and evaluation
• Lack of strategic direction and cross-organizational
performance incentives
• Problems of attribution and trivializing innovation
• Trivializing outcomes
• The practice of lacks rigor
• A lack of purpose

13. The UN Critique (2)
• Lack of clarity on the consequences of good and
poor performance
• Lack of clarity on the capacity needed to build a
results-based management system
• Technical solutions are not a substitute for
substantive clarity

14. The logic of an
evolutionary strategy
 Box et al (1978, p. 303):
 ... the best time to design an experiment is after it is finished, the
converse is that the worst time is the beginning, when least is known.
If the entire experiment was designed at the outset, the
following would have to be assumed as known: (1) which
variables were the most important, (2) over what ranges the
variables should be studied... The experimenter is least able to
answer such questions at the outset of an investigation but
gradually becomes more able to do so as a program evolves. (p.
303)
14

15. What kind of evaluation will you be doing?
Formative
Developmental
Summative
15

16. A Ten Step approach to Evualation
A
INTERVENTION THEORY AND
DEVELOPING EXPECTATIONS OF
IMPACTS OVER TIME
B
The key components of the complex
intervention
The pathways of influence of
an evaluation
The program theory of the complex
intervention
Learning framework for the
evaluation
Learning from the Evidence Base
The anticipated timeline of impact
C
IMPACTS AND LEARNING
LEARNING FRAMEWORKS
AND PATHWAYS OF
INFLUENCE
D
SPREAD AND SUSTAINABILITY
Assessing the impact of the
intervention: DESIGN
Spreading learning from an
evaluation
Learning about the intervention
over time
Reflections on performance and
sustainability
16

17. An Example: Primary Prevention Have a Heart
Paisley
On what basis do
we make a
decision to
SUSTAIN the
program?
What gets
SPREAD as a
result of the
evaluation?
What are the key
LEARNINGS
from the
evaluation?

18. POLICY
LANDSCAPE
(dynamic, changes
over time)
B
D
E
A
EVIDENCE
PROGRAMMES
Evaluator
THEORY
C
Hypothesised
Pathways
Evidence Base
Linked to Pathways
Areas of Uncertainty
EVALUATION
Design, methods,
approaches
PROCESS
LEARNING
RISK
LANDSCAPE
ORGANISATIONA
L LEARNING
INDIVIDUA
L IMPACTS
POLICY
IMPACT
ALIGNMENT
(moving beyond
programmes at level
of analysis)
Interpersonal,
Individual &
Collective
Mechanisms
ACTION

19. Example 1
19

20. Background
• Project in Collaboration with the China National
Health Development Research Centre to build
Evaluation Capacity for evaluating health system
reform efforts
• Focus on Health Inequities
• Developing guidelines to evaluate health inequity
initiatives
• Relationship to complexity
20

21. • Literature
Reviews
• Surveys of
Innovations
• Determine
Evaluation Assets
and Needs
Create
Guidelines
Evaluate 3
projects:
Revise
Guidelines
Levels of Evaluation
Influence
Test and
Refine the
Guidelines
Individual
Inter-personal
Collective
Evaluation Capacity Building
Knowledge Translation
21

22. Evaluation Approach
Complexity of Intervention
22

23. Approach to Evaluation
Complexity of Intervention
23

24. Review of articles
Context
Expectations and
timelines
Understanding and
changing
understanding
Organizational
structures for
learning
Multiple
understandings of
impacts
Sustainability and
spread
24

25. Describe
the
Interventio
n
What was the
Setting of the
intervention?
What was the
Context?
What was the
duration of
the
intervention?
Discussion
on timelines
and
trajectories of
impacts?
Was there a
discussion of the
evidence
informing the
program? Was
the evidence
from multiple
disciplines?
Is the
program a
pilot?
Challenges of
adaptation to
specific
setting?
Were there
changes in the
intervention
over time? How
did the
evaluation
explore this?
Was the
theory of
change
described?
Did it change
over time?
25

26. What was the
Intervention
Planners’
view of
success?
Were there
formal
structures to
learn and
modify the
program over
time?
Was the
organization
al structure
of the
intervention
described?
How were
impacts
studied; what
design were
implemented
?
Was the program a
success?
Unintended
outcomes?
Differential impacts
for different
groups?
Did the
evaluation help
with decisions
about
sustainability?
Was there a
Formal process
of ruling out
threats to
internal and
external
validity?
Was there a
discussion of
what can be
spread as part
of learnings
from the
evaluation?
26

27. Example 2
27

28. Goals
“To contribute to improving health and strengthening
health systems in low and middle income countries
(LMICs), by supporting innovative international
approaches to integrating health knowledge generation
and synthesis (including consideration of
environmental, economic, socio-cultural, and public
policy factors) through research, health research
capacity development, and the use of research
evidence for health policy and practice.”

29. Objectives
• Foster international partnerships and collaboration to
promote the generation and effective communication
and use of relevant health research (including
consideration of environmental, economic, sociocultural, and public policy factors) in, for and by lowand middle-income countries (LMICs);
• Train and support researchers responsive to policy
and practice priorities of LMICs relating to or
influencing health; and
•
Support active collaboration between researchers
and research users (e.g. policymakers, practitioners,
civil society organizations, and community members)
to support health priorities of LMICs.

30. Basic Questions
How complete is our knowledge of how these
initiatives are intended to work?
Do we have clarity on the timeline of impact of
such initiatives?
How do we ensure that we don‟t get caught up in
the „activity space‟ of such initiatives?
How do we align metrics to provide incentives to
focus on the outcomes?

31. •
Key Concepts
Limited sphere of control
•
•
Flexible sphere of control
Timeline of impact
• Metrics and incentives
•
Integrated planning and evaluation

32. The Problem of
Insufficient Imagination

33. Granting
Mechanisms
Research,
Capacity
Building and
Knowledge
Translation
activities
Health
Impacts

34. 4. MERIT
REVIEW
B
D
3. NORTH-SOUTH
RESEARCHERS
AND KNOWLEDGE
USERS
RESPOND TO
REQUEST FOR
PROPOSALS
G
F
6.
BUILDING
TEAMS: INITIAL
RELATIONSHIP
BUILDING
H
K
10.
STRENGTHENE
D
RELATIONSHIP
S BETWEEN
NORTH AND
SOUTH
RESEARCHERS
L
11.
KNOWLEDGE
USER
ENABLED TO
IMPLEMENT
LEARNINGS
M
12. ENABLED
RESEARCHERST
O
P
14. GREATER
AWARENESS
OF
SALIENCE OF
RESEARCH
AND
CAPACITY
BUILDING
FOR LOCAL
POLICY AND
PRACTICE
CONCERNS
V
Z
Q
AA
BB
20. IMPROVED HEALTH
E
J
9. ENHANCED
RESEARCH
CAPACITY AND
CAPACITY TO
USE EVIDENCE
U
19. STRENGTHENED HEALTH SYSTEMS AND ENHANCED
HEALTH EQUITY
5.
IMPLEMENTATI
ON OF
PROJECTS
N
13.
RESEARCH
DISSEMINATI
ON
18. LOCAL USE AND INFLUENCE OF RESEARCH AND CAPACITY
BUILDING
C
8. KNOWLEDGE
GENERATION:
FOCUSSED AND
CROSS-CUTTING
THEMES
16. PLANNING FOR IMPLEMENTATION: ALIGNMENT OF
RESEARCH AND CAPACITY BUILDING WITH LOCAL POLICY AND
PRACTICE NEEDS
1. DRIVERS
FOR THE
DEVELOPMENT
OF TEASDALECORTI
I
7. RESEARCH ,CAPACITY BUILDING AND KNOWLEDGE
TRANSLATION PROCESSES and OUTPUTS
A
2.
COMMISSIONI
NG RESEARCH
AND CAPACITY
BUILDING AND
KNOWLEDGE
TRANSLATION
GRANTS :
TEAM AND
LEADERSHIP
GRANTS, KTE
GRANTS
Indirect
Influence
Direct Influence
Direct Control
CC
R
S
15. ENHANCED
LOCAL
FOUNDATIONS
FOR FUTURE
RESEARCH
AND CAPACITY
BUILDING
W
X
17.
MECHANISMS
TO SUSTAIN
RELATIONSHI
PS AND
FOUNDATION
S

35. Data
Interviews with Teasdale-Corti
planners in multiple funding
organizations including CIHR
and IDRC
Formal analysis of 8 final
reports
Interviews with grantees at
the October 2012 GHRI
Ottawa meeting—this
includes video interviews with
grantees
Brief case studies of three
grantees including Skype
interviews with Southern
partners
Formal analysis of 8 proposals
Bibliometrics analysis
Surveys of Teasdale-Corti
grantees—separate surveys
were conducted with
Canadian researchers,
Southern researchers and
knowledge users
Data collection to support
theory of change work.

36. Support from evidence
• There was strong support from the
evidence for the overall goal of TeasdaleCorti: there was support for how
Teasdale-Corti contributed to building
research and practice that can
contribute to health and strengthening
health systems.
• There was limited evidence that the
Teasdale-Corti initiative directly impacted
health outcomes (but need to reflect on
the timeline of impact)

37. Some learnings (1)
•
•
•
•
•
•
Greater upfront clarity of the anticipated
timeline of impact
Greater upfront thinking about planning for
sustainability
Greater clarity around who counts as a
knowledge user
Focused monitoring on knowledge-user
engagement: possible metrics
Greater clarity on what equity in partnerships
means
Boundaries and contexts of the Teasdale-Corti
model

38. Some learnings (2)
• Limited focus on health equity
• Greater clarify on amount and types of support
•
•
•
•
grantees need
Focus on the end-user and not just the
knowledge user
Greater focus on the benefits of the North-South
relationships
Greater clarity on what progress and
accountability means given the complexity of
Teasdale-Corti
Incentives in the system of metrics to encourage
collaboration and co-creation

39. Refining the Theory of Change:
examples of learnings
Greater clarity (by providing models,
exemplars, narratives of successful
implementation, etc.) on how best to
create synergy between knowledge
generation, knowledge translation and
capacity building
More explicitly clarify the role of the
knowledge user in the implementation
of Teasdale-Corti
Explicitly recognize the „values‟ that
guide the implementation of TeasdaleCorti
The implementation of the theory of
change needs to be supported by a
M&E system that pays attention to the
complexities and heterogeneities of the
implementation of Teasdale-Corti

40. Towards a more
imagined plan

41. 1
2
Problem Definition
3
LMIC Priorities:
4
Promoting Research Use and
Influence
Designing Locally-Useful Research
5
6
Potential for Useful Capacity
Building:
Collaboration

42. 7
8
Equity
9
Sustainability
10
Timeline of Impact:
Clarity and coherence of outcomes and
specific theory of change
11
Monitoring/Evaluation Plan:
12
Gender and Ethical Considerations:

43. Ideas for improvement
Recommendations based on proposal
analysis
• More explicit focus on barriers
• Have a clearer focus on the diversity of knowledge
users
• Equity should have a more explicit focus
• Encourage thinking about sustainability upfront
• Planning for relationship-building over time
• Monitoring and evaluation of complex interventions

44. The ‘blackbox’ of
capacitybuilding
Synergizing
activities
Long timeline
of impact that
may exist for
research to
influence health
outcomes
Consistency
in values
and metrics
Non-linear
models of the
research/poli
cy interface

45. Unpacking the Plan
Theory of Change
Developmental - what are capacities needed?
Sphere of Control
Timeline of Impact
Metrics and incentives
Phased approach to commissioning

46. Evaluating research
• What are pathways of influence by which research
impacts policies?
• Can a results based culture help with greater
understanding of the pathways of influence?
• Approaches:
o Conceptualizing research as an intervention with short and long term
goals. One of the intermediate goals is to influence policy. The long term
goal is to improve individual lives

47. Research as
Intervention
Individual
Research
Project
?
Policy
Influence
Social
Betterment
Monitoring
and
Evaluation
Monitoring
and
Evaluation
Monitoring
and
Evaluation
Monitoring
and
Evaluation
Evaluative
Thinking
Evaluative
Thinking
Evaluative
Thinking
Evaluative
Thinking
Multiple
research
projects

48. Research Quality
Monitorin
g and
Evaluation
System
Pathways
of Policy
Influence

49. Research
as
Interventio
n
Context
Mechanis
ms
Outcomes

50. MODEL 1
From
Knowledge to
Policy
See Knowledge to Policy: Making the
most of Development Research, Fred
Carden, 2009

51. Overall Context
Stability of Decision
Making Institutions
Research as
Intervention
Research
Quality
Research
Network
s
Policy Absorption
Capacity
Nature of Governance
Opportunities for
countries in transition
Economic crisis and
pressures on
government
Action
Research
Government Context
Clear Government
Demand
New
tools
Government interest
but leadership absent
Interest but no
capacity
Interesting research
but research
uninteresting for
Government
Government
disinterest or
Mechanism
: So, what
can you do?
Relationship
Building
Communica
tion
Networks of
Influence
Institutional
Mechanisms
Process
Outcomes
Policy
Capacity
Broader
Policy
Horizons
Policy
Regimes
Outcomes
Policy
Influence
‚Better‛
Decisions
Social
Betterment

52. Model 2:
Pathways of
Influence
Mel Mark and Gary Henry, Evaluation,
2003

55. Research Initiatives in
specific places
• Local research for lasting solutions
• Some key questions:
o What is local about your research? How does your research respond to
local needs? What is different about your local networks? What is the
value added of the local research?
o Are there local pathways of influence?
o How different are the local pathways of influence from other more
general pathways?

56. Global
Context
Research
as
Interventio
n
Global
Mechanis
ms
Outcomes
Local
Context
Local
Mechanis
ms

57. Local Context
• Are your theories locally generated? Are the needs
local?
• Examples of local context that have interfered with
standard influence processes
• Does your research address local needs in a timely
manner?
• Are the local networks different from other more
general networks of influence?
• Example: What are some of the challenges of policy
influence in specific contexts in Africa?

58. Summing up and looking
ahead
58

59. Models of Causation
(Successionist vs.
Generative Models
of Causation)
Integrating
Knowledge
Translation with
evaluation
Development al
evaluation in
Complex
Dynamic
Settings
Ecology of
Evidence
Capacity
Building
Portfolio of
designs
and approaches
Program Theory
and
Incompleteness
Time Horizons
and Functional
forms
Spread, Scaling
up and
Generalization
59