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The WHO Strategic Approach    |    Situation Analysis

Service Provision Assessment    |    Service Availability Mapping


Peter Fajans and Ronnie Johnson


The Strategic Approach is a three-stage process to assist countries in strengthening their sexual and reproductive health policies and programmes in the context of the overall national health sector planning process.


The first stage is a Strategic Assessment to identify national programmatic needs and priorities. It takes a systems perspective and focuses on:

the needs and desires of current and potential users of services;

the current policies and institutional capacities of the health system to provide equitable
   access to quality services; and

the mix of available technologies and other reproductive health interventions.


It attempts to understand their relationships, and how they are influenced by their social, cultural, political and economic context. A variety of recommendations for policy and programme strengthening typically emerge from a strategic assessment.


The second stage of the Strategic Approach involves testing policy and programmatic interventions to improve equitable access, utilization and quality of care in service delivery.

In the third stage, findings from the first two stages are used to scale up interventions for wider impact. The Strategic Assessment embodies “beginning with the end in mind” as the key first step to successful scaling-up.


The assessments are participatory and field-based, using predominantly qualitative methods to generate in-depth understanding of the barriers to equitable access, utilization and provision of quality client-centred services, as well as to build consensus among stakeholders for potential solutions.

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Key Elements

Strengths of the tool The strategic assessment’s strengths include developing an in-depth understanding about barriers to equitable access and utilization of sexual and reproductive health services, as well as to the provision of comprehensive, high quality sexual and reproductive health services. The tool allows for exploring the feasibility of different policy and programme options that provide potential solutions to existing challenges. The participatory process of conducting a strategic assessment has resulted in increased collaboration among government agencies and civil society organizations.

In a number of countries the country-owned and country-led nature of the strategic assessment has provided a means for the Ministry of Health to provide more coherent input to donors concerning national needs and priorities, helping to strengthen coordination among SRH related partners in the country. The findings and recommendations of strategic assessments have also been valuable tools for advocacy for increased investment in reproductive health services. In addition to its utility for policy and programme development, the strategic assessment methodology can also be adapted as a tool for formative programme evaluation.


Limitations of the tool The strategic assessment does not produce quantitative data on health service outputs or health outcomes; generalizable information requiring statistical precision; detailed information on specific operational aspects of services such as management information or logistic systems; or in-depth understanding of the socio-cultural dimensions of a specific reproductive health issue, such as the effects of gender relations on contraceptive use in a particular setting.

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Principles and Steps for Using the Tool
Partners It is critical to involve a broad range of stakeholders, including representatives of civil society.


Target Fieldwork locations are selected to provide an overview of the situation
in a range of different conditions, including different cultural and geographical regions,
in areas with relatively strong services and in those where provision of services is
more challenging.


Methodology In each location, in-depth interviews, group discussions and observations are conducted at all levels of the health service delivery system, as well as in the communities they serve. Typically 15 to 25 different service-delivery facilities are visited and open-ended interviews and group discussions conducted with 200-500 people.

The emphasis on qualitative techniques is intended to develop in-depth understanding of the determinants of access and utilization of services and the quality of care provided, including the perspectives of community members. Daily group discussions among team members review what has been learned that day and reach consensus on findings, emerging themes and preliminary recommendations for interventions.


Time required The process of a strategic assessment is flexible, depending on local circumstances and the issues being addressed. From initial planning to distribution of the final report, a strategic assessment takes anywhere from six months to a year. The timeline in different countries has been greatly influenced by time taken for proposal development and review, availability of funding, turnover of key Ministry of Health personnel, transport, communications and seasonal considerations.


Human resources A senior programme manager typically leads the team, often assisted by several junior staff. The assessment team typically consists of 10 to 18 members, depending upon their availability for the duration of the two- or three-week fieldwork period, the size of the geographical area to be covered and funds. One or
more experienced external facilitators support the participatory process and provide technical input.


Budget line items The cost of strategic assessment has varied from country to country, ranging from a low of approximately $25,000 to nearly $150,000, with a median of around $75,000. Many factors influence the budget, including transportation costs,
the number of participants in the planning workshops, and honoraria for participants
and field workers.

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Adaptation and Technical Assistance

experience with the tool The Strategic Approach has now been used by over 30 countries (at the sub-national level in India and China) to address a wide range of sexual and reproductive health issues, including family planning, maternal health and the prevention of unsafe abortion, adolescent health, and the prevention and treatment of sexually transmitted infections, HIV/AIDS and cervical cancer. Ten countries have conducted two or more strategic assessments to support policy and programme development for different reproductive health issues.


Recommendations for adaptation

Four Steps for Conducting a Strategic Assessment


Step 1 - Lay the foundation
Identify key issues to be addressed.
Develop a proposal and mobilize resources.
Identify the strategic assessment leader and other team members.
Identify other key stakeholders.
Identify locations for fieldwork.


Step 2 - Prepare for fieldwork
Prepare a background paper including information on policies,
   programmes and research findings.
Formulate “strategic questions” to guide the assessment.
Convene a national planning workshop for key stakeholders.
Orient and train the assessment team and develop guides for field
   discussions and observations.
Confirm fieldwork locations and complete administrative and
   logistical arrangements.


Step 3 - Fieldwork
Over a two to three-week period, conduct in-depth individual and group
   discussions with: programme managers and service delivery providers at
   different levels of the health system; users of reproductive health services,
   and a broad range of community members.
Observe facilities and client- and patient-provider interactions.
Review available service statistics.
Continuously discuss and analyse information generated and formulate
   preliminary recommendations.
Develop an initial draft report while in the field.


Step 4 - Link recommendations to actions
Complete the draft report immediately after the fieldwork.
Circulate the report to team members and other key stakeholders for
   review and feedback.

Convene a workshop to share the findings and recommendations with key    stakeholders, including local donors and technical support organizations.
Plan for follow-up to link the assessment recommendations to policy,
   programme, and research interventions.
Finalize and distribute the assessment report.


Samples of questionnaires used by this tool can be found at:
the Bank of Sample Questionnaires

Possibilities for technical assistance and contact information
Further information and other resources for those interested in implementing a strategic assessment are available on the WHO Department of Reproductive Health and Research website. In particular, the following documents are recommended: The WHO Strategic Approach to Strengthening Sexual and Reproductive Health Policies and Programmes:
A Brief Introduction to the WHO Strategic Approach, which includes a description of
the three-stage approach and country examples. Available in English, French,
Russian, and Spanish.

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Making Decisions about Contraceptive Introduction: A Guide for Conducting Assessments to Broaden Contraceptive Choice and Improve Quality of Care

A field guide to conducting strategic assessments addressing contraceptive introduction and quality of care in family planning services. Although the Strategic Approach was initially developed and field-tested as a systematic approach to contraceptive introduction, this guide has been adapted for strategic assessments on other sexual and reproductive health issues. A new generic guide for conducting strategic assessments will be available in early 2009.


Additional information about the Strategic Approach, including examples of country reports of strategic assessments, can be found on WHO’s Department of Reproductive Health and Research website:


For more information please contact:
Department of Reproductive Health and Research
World Health Organization
Avenue Appia 20
Ch-1211 Geneva 27
Fax +41 22 791 4171

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The WHO Strategic Approach Photo

© Ken Opprann/Norway

Shortcuts within this document:


Key Elements

Principle and Steps for Using the Tool

Adaption and Technical Assistance

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