Conducting an Assessment to improve Sexual and Reproductive Health Programmes

Effective sexual and reproductive health interventions vary depending on the needs they respond to, and the place; the political, social and cultural context; the economic situation, and the quality and availability of health services. Successful interventions developed in one context must be modified before they will fit local needs elsewhere, whether in another country or another region in the same country.

Before investing in interventions it is essential to:

• Understand the nature of and influences on sexual and reproductive health problems,    such as:

– population groups;

– social, cultural, economic, political and religious environments and contexts;

– risk-taking and health-seeking behaviours, and factors influencing them;

– means, including health systems, to prevent and treat problems, 
   and rehabilitate people affected.

• Identify major determinants of problems to be addressed.

• Identify resources, available or potential, including any other ongoing or planned    assessments, and whether they are related to these problems.

• Understand the perspectives and roles of different actors who might 
   support positive change.

• Use the assessment to design and implement realistic and feasible interventions which
   respond to local conditions.

• Use the information from the assessment as a baseline to monitor the progress and
   evaluating the results of the intervention. If the methodology and rigour of the initial
   assessment are not appropriate for monitoring, it may be necessary to establish a
   separate baseline for the purpose.

Assessments are intended to help in developing interventions. Their usefulness depends on their practicality, their contribution to decision-making and their capacity to be transformed into interventions. Interventions based on a realistic and accurate assessment make the best use of precious time and resources. The final test of a successful assessment will be successful implementation based on it.

Steps for Conducting a Sexual and Reproductive 
Health Assessment

An assessment should be part of a process leading to appropriate interventions, except when assessment methods are used as evaluation tools. The process consists of a series of steps, which should be taken as far as possible in order, modifying as necessary as the process continues. For example, step 1 is to define the problem; but the stakeholders’ meeting (step 2) may provide new information and perspectives. If necessary, the assessment may skip a step and return to it at a later stage–in real life, the process is seldom linear.

It will be very helpful to establish an oversight group at the outset representing all stakeholders. The task of this “core team” will be to coordinate the partners managing the different parts of the assessment.

1. Describe the problem

A useful assessment starts when programme managers or people affected become aware of a problem and decide to address it. Developing an intervention usually calls for more information about causes and contributing factors; people and communities affected; its context and geographic area, and identification of possible approaches. Listing these factors and looking at interactions among them helps to describe the problem.

This is a healthy start for an assessment, in contrast with a process in which donors or academics identify both problem and solution from outside the context and maybe even the country concerned. Such a process is less likely to lead to meaningful interventions – or even to reach local stakeholders and be put into effect.

2. Bring together stakeholders

The next step is to bring together representatives of the various stakeholders. The first group are those responsible for developing and carrying out interventions, for example health care providers, concerned NGOs and the Ministry of Health. The second group are affected individuals and communities. Their perceived needs are the starting point: they are part of the solution, not merely passive recipients of services provided to them.

It is also important to include technical experts as early as possible in the process. 
They will contribute to defining the problem, for example the feasibility of including 
different populations and geographic areas, and help estimate financial, time and human resource needs.

It is important to include key individuals in the core team and ensure that it is acceptable to all stakeholders. This will increase their sense of ownership and improve co-ordination.

3. Identify the type of information needed

One of the most challenging steps of an assessment is to decide on specific topics and what information is needed. Failure to collect essential information will hold back decision-making and the development of an effective intervention. On the other hand collecting too much information will increase the length and cost of the assessment. Working groups of stakeholders can determine the right questions, with the help of technical experts. Lists of indicators developed and pretested in advance may be helpful for collecting some of the information.^1,2 A list of indicators, developed by WHO and UNFPA for monitoring achievement of universal access to reproductive health can be found in the Bank of Sample Questionnaires.³ Existing questionnaires or interview guidelines may also help.⁴ During this process it is important to identify resources and opportunities for the intervention and critically examine the questions for relevance.

4. Build on what exists: the desktop review

Mapping, critically evaluating and putting together existing information will save time and energy, improve understanding of the problem and its context, and avoid duplication of effort. Routinely collected international and government statistics, policy documents and local research can provide valuable data and insight, and help to identify gaps in current knowledge. Demographic health surveys, household surveys, and academic research are also useful. Using this data calls for critical evaluation of their reliability and the degree to which they reflect reality. Stakeholder meetings will amplify information from these sources.

5. Share the results with stakeholders

The completion of the desktop review is a good point to bring stakeholders together to discuss results and collaborate in:

• Identifying available political, financial and human resources and planning fundraising;

• Deciding the time-frame for the assessment;

• Deciding the target geographic area and population;

• Deciding the type of sampling;

• Deciding how and when to share results with stakeholders;

• Deciding how to use the results of the review in planning the intervention, and

• Selecting a steering committee if needed.

6. Choose the right tool

The choice of methodology for the needs assessment will depend on the type of questions to be answered; the depth of detail and accuracy needed; the human and financial resources available and the time-frame. It is essential to understand the different methodologies and know the advantages and disadvantages of each in different circumstances and for different purposes. Questionnaires and other instruments already used and validated elsewhere may provide a useful starting point.

Either the stakeholders’ meeting or the core group can decide on the methodology, calling on experts as required. Technical experts will be largely responsible for steps 7 to 12.

7. Develop or adapt instruments, pretest, conduct sampling

If the assessment is using a methodology already used elsewhere, it may be possible to adapt existing questionnaires, guides for individual and group discussions, and observations of facilities and services; if not, it will be necessary to prepare the materials afresh. In either case it is important to call on technical expertise and advice. The core group may work on the questions and issues to be addressed, using the decisions from the stakeholders’ group.

Once ready, the questionnaires (or interview and observation guides) should be pretested at a representative setting in the field, to identify any problems. During this step, sampling – selection of the settings for carrying out the assessment – should also be conducted. Sampling will depend on the chosen methodology.

8. Recruit and train staff 

According to the assessment plan and depending on human resources already available new staff need to be recruited and trained for interviewing, supervisory roles, data entry and data management.

9. Plan data collection and analysis, and collect data

Before field work starts, data collection and entry, analysis of the results and management during the whole process must be planned and the necessary staff recruited and trained. These are usually highly technical issues calling for joint planning with experts.

10. Analyse results and share with stakeholders 

The technical team must analyse results in accordance with the methodology used. It is advisable to examine and discuss preliminary results with the technical team before preparing the final report. It may be more productive to share the results with stakeholders too at this stage.

11. Write and disseminate the action plan and final report 

An action plan based on the results may be prepared at the same time as the final report. The action plan and the final report can then be disseminated together, offering opportunities for advocacy and fund raising, and attracting more partners for the implementation stage.

12. Build in monitoring and plan for assessment of results

The indicators used in the assessment may also be applied at the implementation stage, facilitating development of a built-in monitoring and evaluation plan for the intervention.

13. Implement interventions, monitor progress, assess results, adapt strategies 

This is the final step and the goal of the assessment. A successful assessment may be judged by the success of the intervention, as revealed by monitoring and evaluation. The final evaluation of an intervention will lead to assessment of new needs and development of new interventions.