The conceptual framework is adapted from a similar model developed for family planning (FP) under The EVALUATION Project. This framework illustrates the pathways by which reproductive health (RH) programs achieve their objectives. This framework maps the pathways through which programs achieve results, and it constitutes a logical framework for developing an evaluation plan with appropriate indicators. The original framework, created for FP programs, is readily adaptable to other areas of RH. Many sections of the framework contain more detailed frameworks that explain the pathways for program effects specific to the topic area in question.
Whereas some past evaluation efforts have treated the operations of RH programs as a "black box," this framework specifies how those who design the program expect it to work to achieve results at both the program and population level. Moreover, the framework draws attention to the different aspects of programs (operational areas, access to services, quality of care) that must be working satisfactorily to achieve the desired end result.
(Click on the framework to enlarge.)
The column on the far left defines the context in which the program operates: the social, cultural, economic, political, and legal systems in a given society, including that society's reproductive health programs. The top left-hand side of the figure, lightly shaded, outlines the role of demand in the effectiveness of a given program. Countries in which the population actively wants the services ("high demand") based on societal norms and preferences will have a far easier time achieving results than those in which the population is indifferent or outwardly negative toward the program.
The lower left-hand side of the framework lists factors in the supply environment, shaded in a darker tone. Countries with strong social and economic development programs provide a more conducive environment in which to promote RH than those without systems to support such efforts. Strong political support ("political will") for a program also facilitates implementation, as illustrated by the FP program in Bangladesh. Whereas donor agencies and program managers once treated policy as a contextual variable that would influence program implementation, today they actively design interventions (e.g., advocacy) with the aim of shaping the policy environment.
The supply environment also comprises the functional areas that support service delivery and the service delivery environment itself. The functional or operational areas of a program provide the structure for carrying out interventions, including management, training, logistics, research/evaluation, and BCC (in the clinic or the community). Indeed, USAID and other donor agencies fund entire programs that strengthen the operations in these areas in developing countries. These functional areas contribute directly to the services available to a prospective client in a given country. Measures of the service delivery environment focus on access to services and quality of care as well as sub-elements of quality: integration of services and gender equity/sensitivity.
These two sets of factors -- supply and demand -- jointly determine the level of service utilization in a given country. Although service utilization is not essential to the practice of certain behaviors (e.g., sexual abstinence, condom use, exclusive breastfeeding), it generally plays a key role in helping a client adopt healthy behaviors, through information and counseling (e.g., proper use of Standard Days Method, correct condom use, tips for adhering to exclusive breastfeeding), provision of supplies (e.g., contraceptive pills, condoms for pregnancy and sexually transmitted disease prevention), or clinical procedures (e.g., IUD insertion, surgical sterilization, male circumcision).
The box labeled "health behaviors" represents the objective of most RH programs: that is, the behaviors that members of the intended audience are encouraged to adopt. Examples include use of contraception for FP, use of condoms or decrease in number of sexual partners for HIV prevention, delivery with a skilled birth attendant, and exclusive breastfeeding. It is important to recognize that non-program factors may also play a role at this level in influencing both health behaviors and outcomes. For example, gender norms and gender inequalities may influence women's health behaviors. For instance, women's limited control over decisions that affect their health and limited access to resources (e.g., transportation) makes it difficult for them to use services. Women are more susceptible to contracting HIV from an infected partner than men are. Fertility is determined not only by contraceptive use, but also age at marriage, extent of induced abortion, postpartum infecundability, and pathological sterility. The entire chain of causal events leading to specific health behaviors directly affects the ultimate objective of RH programs: improved health outcomes in terms of fertility, mortality, and morbidity.