A conceptual framework for training of trainers (ToT) interventions in global health.

BACKGROUND: Global health partnerships (GHP) between high or low-middle income countries are considered one of the best approaches to health systems strengthening. They typically involve highly skilled healthcare workers who volunteer to deliver capacity strengthening projects overseas, often in the form of peer-to-peer support through training and mentoring. Given GHP's strong focus on education and training, a common assumption is that training of trainers (ToT) is a strong predictor of sustainability because of its potential for up-skilling the workforce rapidly, cheaply and exponentially by developing local educators. Our aim is to test this assumption and identify the strengths and limitations of this approach by analysing qualitative data from a set of GHP funded by the UK Department for International Development through the Tropical Health and Education Trust. RESULTS: Our analysis identifies some of the common features of the ToT model and a number of limitations that can prevent it from being both effective and sustainable. Whilst most GHP strive for the long-term sustainability of the training by focusing on adequate training provision and support of local trainers, the wider issues that can facilitate or prevent the continuation of training are not always considered. We propose a conceptual framework (TRAIN) for ToT interventions to help inform practice and project evaluation. We illustrate the applicability of our framework through five case studies, each chosen to illustrate one aspect of the framework. CONCLUSIONS: TRAIN is intended as a starting point for further refinements and discussions about the factors affecting capacity building strategies based on training cascades. Although we envisage its usefulness to GHP as a guidance to design and operationalise ToT, we recognise that in practice it may be difficult to implement it in its entirety. The key message underlying TRAIN is that the sustainability of a cascade depends on a number of factors being present or developing at different operational levels during the course of a project. These are crucial to transform the opportunities that ToT affords to health systems in developing countries into the actual achievement of a training cascade that ultimately upskills the workforce and improves health outcomes in these countries.