Underlying Principles of Good Program Design and Implementation
Though not incorporated visually into the SEED Programming Model™, EngenderHealth subscribes to four underlying principles of good program design and implementation – The Fundamentals of Care, Evidence-Based Programming, Gender Equity, and Stakeholder Engagement.
The Fundamentals of Care
The fundamentals of care are the essential elements of quality services, particularly (though not exclusively) in a clinical setting. The fundamentals of care include:
- Informed choice and voluntary choice and decision making
- Clinical safety
- An ongoing mechanism for quality improvement and quality assurance, based on clients’ rights and staff needs
All clients have the right to informed choice and voluntary decision making based on accurate information on service options, free of negative provider influence. This applies to the availability of and choice among a range of FP methods, as well as decision making related to any clinical procedure related to SRH (e.g., a facility-based delivery, a vasectomy procedure, or testing for HIV). The safety of clinical procedures can be ensured when:
- Providers are skilled and work in a well managed, appropriately equipped service delivery site;
- Procedures are performed according to up-to-date, evidence-based standards, protocols, and guidelines; and
- Infection prevention processes are in place.
Finally, facilitative supervision and quality improvement approaches facilitate problem solving and empower staff and communities to actively engage in ensuring quality standards over time. Facilitative supervision and quality improvement approaches help providers move from actual to desired performance and adopt better practices to improve performance as new evidence emerges.
Evidence-based programming is the explicit use of data and scientific evidence during the design and implementation of a program. It has many manifestations and can include:
- Formative research to assess needs and inform the design of a program
- Use of survey data (e.g., from the Demographic and Health Surveys) to define need and scope of a program
- Use of published research and logical models to select and design intervention activities
- Use of literature reviews and international guidelines or standards to update policies and service protocols
- Incorporation of fact-based information and behavior theory into social and behavior change communication (SBCC) interventions
- Use of service delivery statistics and other data for quality improvement
- Operations research during implementation and scale-up
- Monitoring and evaluation of a program
- Use of data for decision making and program planning (e.g., use of service delivery statistics and population-level data for forecasting)
In many instances, programs are designed and implemented based on intuition, ideology, or past experience, without strong indications that the chosen approaches will be effective. Wherever possible, programs should use locally generated evidence, which can be complemented by international data or evidence where knowledge gaps exist. Taking an evidence-based approach allows programs to target priority needs and use resources efficiently, maximizing the likelihood of programmatic success by avoiding “reinvention of the wheel” and taking advantage of previous experiences and existing knowledge on “what works.” Evidence is also critical to support advocacy efforts. Advocacy efforts backed by scientific data can lead to improved evidence-based policies and programs. Programs should not only use evidence, but also, where feasible, contribute to generating it as well. Monitoring and evaluation, operations research, and documentation and dissemination of results should be built into program design from the onset.
Clearly, women and men have significantly different SRH needs; these are rooted in their biological and socialized roles in reproduction (childbearing) and child-rearing. Yet the gender norms in a given society and the power dynamics between women and men may place “differential constraints on the meeting of those [SRH] needs” (Doyal, 2000). For example, women’s lack of decision making power and limited control over financial resources serve to increase their SRH risks and limit their access to services. Similarly, sociocultural norms surrounding masculinity may hinder men from seeking preventive and curative SRH services.
An equity approach recognizes that women and men face different constraints and have a different level of resources to address their health problems. It is therefore important to evaluate SRH interventions through a gender lens — looking at whether conditions exist for equitable access, equitable participation, and safety from violence and discrimination. Doing so may require dealing with women and men differently, so as to work toward an equal outcome of improved SRH for both sexes (Simpson et al., 2005). As such, the SEED Programming Model™ recognizes the need to challenge and transform harmful social norms, including gender inequity, so that programs can promote positive changes in gender roles to the benefit of improved SRH for both women and men.
Stakeholder engagement is a process of involving those who have a role or an interest in and/or are affected by a program’s activities and goals. This engagement can span a continuum of activities, including dialogue and consultation; collaboration in identifying problems and solutions; partnering in implementation and evaluation; and capacity building and empowerment. Stakeholders may differ at different levels:
- At a national level, stakeholders may include parliamentarians and high-level bureaucrats;
- At the district level, stakeholders may include district officials, health managers, district-level representatives of prominent institutions, and representatives of civil society and nongovernmental organizations;
- At the community level, stakeholders may include local government officials, program managers and service providers, traditional and religious leaders, community health committees and groups, community representatives (including representatives of marginalized groups), client advocates, and beneficiaries of the project.
Stakeholder engagement is critical to program success and sustainability, ensuring that decision makers, program implementers, and the intended beneficiaries are partners in program design, implementation, and oversight. This increases the likelihood that an intervention will address the community’s SRH needs and preferences appropriately. Furthermore, involving stakeholders contributes to program sustainability and ownership, by including those who will be in a better position to carry on or advocate for the program’s work over time.