Abstract
Public sector health systems that provide services to poor and marginalized populations in developing countries face great challenges. Change associated with health sector reform and structural adjustment often leaves these already-strained institutions with fewer resources and insufficient capacity to relieve health burdens.
The Strategic Approach to Strengthening Reproductive Health Policies and Programs is a methodological innovation developed by the World Health Organization and its partners to help countries identify and prioritize their reproductive health service needs, test appropriate interventions, and scale up successful innovations to a subnational or national level. The participatory, interdisciplinary, and country-owned process can set in motion much-needed change.
We describe key features of this approach, provide illustrations from country experiences, and use insights from the diffusion of innovation literature to explain the approach’s dissemination and sustainability.
THE MILLENNIUM DEVELOPMENT Goals and United Nations conferences of the 1990s set an ambitious global agenda for health and development, including reproductive health. National governments were called upon to increase availability and access to services and education, improve quality of care and gender equity, and respond more effectively and equitably to the persistent problems of obstetric emergencies, unwanted pregnancies and unsafe abortions, childhood deaths, and the HIV/AIDS crisis. These expectations are now being raised at a time when weak public sector health institutions are in a process of transformation. Structural adjustment policies and economic downturns have reduced the resource base available to the public sector; moreover, health sector reform is confronting public health services with uncertainty and ongoing change.1–4 Added to an already weak institutional capacity, these conditions make it difficult for health systems to innovate.
Because of this dilemma, it is essential to identify strategies that allow governments to respond to the needs and challenges of their constituents. The Strategic Approach to Strengthening Reproductive Health Policies and Programs, or simply the Strategic Approach, is a method for building such capacity. It enables countries to identify and prioritize service needs, test appropriate interventions, and then scale up successful innovations to a subnational or national level. Innovation here is defined as “an idea, practice, or object that is perceived as new by an individual or other unit of adoption.”5(p11) As Rogers noted,5 it matters little whether the practice is new or whether it is only perceived to be new—if it is perceived to be new, it is considered to be an innovation. The Strategic Approach assists governments with innovating and is itself an innovation because it differs from other approaches. It is not a panacea or a magic bullet but an incremental, interdisciplinary, and country-owned process that can set in motion much-needed change.
The Strategic Approach was originally developed by the World Health Organization (WHO) and its partners to reorient the introduction of contraceptive methods from a technology-driven approach to one that is focused on quality of care and people’s needs and rights.6–9 As countries began to apply the Strategic Approach during the 1990s, it was met with considerable enthusiasm. More and more governments requested assistance with applying the methodology. The Strategic Approach has now been implemented in 25 countries and has been adapted to be applicable for a range of reproductive health concerns (Table 1). Seven countries have conducted its first stage—the strategic assessment of needs—2 or more times to address different reproductive health concerns or programming challenges. Although the Strategic Approach to date has been applied only to reproductive health, it is applicable to other areas of public health.
The Strategic Approach has 4 key features: (1) a philosophy of reproductive health that embraces reproductive rights, gender equity, and social justice; (2) linkage between the strategic needs assessment, applied service delivery research, and scaling up of successful innovations; (3) a client-centered systems framework for identifying and correcting the management, technical, sociocultural, and resource problems that affect a health system’s ability to provide equitable access to appropriate services of good quality; and (4) country ownership and a participatory process for involving program managers, policymakers, and other relevant stakeholders, including representatives of governmental, nongovernmental, and professional organizations; service providers; researchers; social scientists; women’s health advocates; and influential leaders of women’s, youth, and community groups. Each feature represents an innovation on its own and as a whole.
The Strategic Approach works within the concept of reproductive health as articulated by WHO,10 and it embraces the values of sexual and reproductive rights, gender equity, and empowerment of women as defined by international conferences and agreements during the past 10 years (the 1994 International Conference on Population and Development, the 1995 Fourth World Conference on Women, and the 2000 Millennium Declaration). Such a philosophy is sometimes poorly understood at country and local levels. The Strategic Approach shows how these values reframe the perception of reproductive health problems and the solutions that are available, e.g., when developing family planning services, quality of care, informed choice, and linkages to other reproductive health topics become the goal of interventions rather than contraceptive prevalence. Moreover, people’s reproductive health needs and preferences, in addition to epidemiological indicators, determine how services are prioritized and organized.
The basis of the Strategic Approach is the premise that governments will increase their capacity to respond to urgent health needs if they proceed through a phased process of policy and program strengthening (Figure 1). At the core of this process are 3 stages of work: a strategic assessment of needs, service delivery research, and scaling up of successful innovations.
The first stage—strategic assessment of needs—differs from other needs assessment approaches in its conceptual framework and participatory process.8,11 During preliminary planning, experienced facilitators familiarize government health officials with the Strategic Approach methodology, and the initial plans for an assessment are made. The process is formally initiated with a workshop, where the aforementioned stakeholders review a background paper that summarizes existing knowledge and makes recommendations about the central issues to be addressed. Fieldwork is then undertaken by a national, multidisciplinary, high-level team from the array of relevant stakeholders, who make service delivery observations and conduct in-depth interviews with policymakers, program managers, providers, service users, and community members. Senior program managers typically do not have opportunities to obtain first-hand accounts from local people and service providers about the problems associated with obtaining or providing good quality health care. This experience results in a greater ability to identify, test, and implement solutions that focus on the real needs of local people and grassroots providers.
The purpose of the second stage—applied service delivery research—is to design and obtain evidence of the effectiveness and feasibility of innovations that will attend to priorities identified by the assessment before investing resources in large-scale efforts. Research often involves pilot testing innovations to enhance access, availability, and quality of care within existing institutional and resource constraints. This research continues to involve a broad range of stakeholders in its implementation.
Using the results from the first 2 stages, the third stage—the scaling up of successful innovations—focuses on policy dialogue, planning, and action to facilitate program expansion. Decisions are made about how and when to move from small-scale projects to a wider implementation. Such a deliberate focus on scaling up, with attention to evaluation and research, is a departure from prevailing practice and seeks to overcome the limited impact of most pilot research.12–14
The Strategic Approach is guided by a systems framework that directs attention to the critical issues affecting the acceptability and sustainability of a health service innovation or technology (Figure 2).15–17 Systems thinking stipulates that decisionmaking should consider the relationships between people, policies and management, and the mix of available services and technologies. It also should consider how these relationships are influenced by social, cultural, political, resource, and health sector contexts. The framework draws attention to the opportunities and the limits of public sector institutional capacities when health systems seek to improve quality of care, expand service options, and introduce gender- and rights-based perspectives in the development of client-centered services. The use of a client-centered systems framework is innovative because it takes into account the complex and interacting forces that determine whether or not a peoples’s perspectives and needs are appropriately served. More commonly, interventions are narrowly focused on specific activities (e.g., adding a new contraceptive method or syndromic management of reproductive tract infections [RTIs]) without considering how the social and institutional contexts affect the potential for success.6
The 3 stages of the Strategic Approach set in motion a participatory process that increases the range of experiences reflected in decisionmaking. For example, the strategic assessment of needs is typically conducted by stakeholders from governmental, nongovernmental, and professional organizations. This is a departure from the practice of limiting health sector decisionmaking to ministries of health. Multiple perspectives generate broad-based knowledge, support, and consensus for proposed actions and make decisionmaking transparent. The Strategic Approach encourages partnerships with donor and international agencies, but places responsibility for decisionmaking and implementation in the hands of country participants. Such emphasis on country ownership differs from dominant international development practice that is often driven by donor interests and donor-led decisionmaking.
The Strategic Approach has produced significant innovations in most of the 25 countries where it has been implemented (Table 1).8 In Zambia, the approach led to the development of a national reproductive health policy and strategy document, service delivery guidelines for family planning, and an agenda for reproductive health research in addition to the testing and scaling up of innovative management strategies for improving access to, and quality of, care.18,19 In Brazil, service delivery research showed how municipal health services could increase access to family planning and expand service coverage from an exclusive focus on women to include adolescents and men.20 In Myanmar, the Department of Health—in addition to strengthening public sector capacities—developed a training curriculum and supported training for private reproductive health practitioners, because people mostly sought care from them. In Romania, the assessment resulted in immediate policy changes to increase access to contraception, particularly among poor rural women, and the development of national standards and guidelines for abortion services.21 More examples of service improvements in developing countries have been published elsewhere.8,9,22–24
Questions about what determines diffusion of innovation are not new. Since the late 1940s, these questions have been the subject of many studies and publications from a wide variety of fields.5,25,26 This literature has identified various factors that affect the successful diffusion of innovations, including attributes of the innovation, the linkage strategy, the innovators or users of the innovation, and the environment in which diffusion takes place.
Glaser et al. identified 7 key characteristics of an innovation that facilitate its wider application.26 Innovations must be (1) based on sound evidence or espoused by respected persons or respected institutions in order to be credible; (2) observable to ensure that potential users can see the results in practice; (3) relevant for resolving persistent or sharply felt problems; (4) shown to have a relative advantage over existing practices so that potential users are convinced that the costs of implementation are offset by benefits; (5) easy to install and understand rather than complex and complicated; (6) compatible with the potential users’ established values, norms, and facilities; and (7) able to be tested or tried without committing the potential user to complete adoption when results have not yet been seen.
According to research, diffusion of an innovation is facilitated by (1) users who perceive a need for the innovation and consider it beneficial and congruent with the system’s central ideas and concepts; (2) user organizations that have the appropriate implementation capacity, values, and openness; (3) appropriate timing and circumstances; (4) user organizations that possesses effective leadership and internal advocacy; and (5) resource (sending) organizations and user organizations that have similar characteristics and are in close physical proximity.5,13,26–29
Leaders in developing countries have turned to the Strategic Approach because of its potential for addressing urgent reproductive health priorities. In some cases, the approach was perceived as relevant for a specific problem. In Vietnam, the government was eager to broaden the contraceptive method mix and asked the United Nations Population Fund to provide supplies of the injectable contraceptive depot medroxyprogesterone acetate (DMPA), which was largely unavailable in the public sector. With 140 000 doses of the newly arrived drug in their warehouse, the Ministry of Health wanted to develop an appropriate strategy for introduction. They chose to work with the Strategic Approach, because they saw it as an opportunity to broaden contraceptive choice and to improve the quality of services in general.23,30,31
The flexibility of the methodology also has proved attractive to national leaders. In Laos, the original interest had been in quality of care for family planning services, but when these plans were discussed with the minister of health, he asked whether the Strategic Approach could be used to explore the linkage between unmet need for family planning and maternal mortality, and to facilitate the integration of contraceptive services with related reproductive health services—such as the need to combine RTI care when providing intrauterine devices. He perceived this broader focus to be a higher priority than family planning alone. Thus, the focus of the Strategic Approach in Laos was broadened to include a range of reproductive health concerns, including maternal and adolescent health and RTIs.32
These examples highlight the critical importance of national ownership. By placing ownership in the hands of national leaders, the Strategic Approach departs from a pattern where donors or other external institutions dominate decisionmaking. In country after country, good work conducted under the auspices of donor initiatives has had limited influence, because national leaders lack a sense of ownership. Country ownership leads to credibility of results and policy impact. At the same time, diffusion of the Strategic Approach has benefited from WHO sponsorship, which links the initiative to an international body that is held in high esteem, because developing countries view WHO as their organization.
By promoting the participation of high-level officials throughout, the Strategic Approach exposes senior leaders to the conditions of service delivery and to people’s needs. This opportunity to see public sector services through the eyes of local people often produces a shocking realization about the extent of needed change. In Mongolia, the team leader commented at the end of the assessment, “I really like this Strategic Approach, which is so good for us. We sit in our offices and think we are doing it right; then we do this strategic assessment and find that it is not right for doctors or for women. Now we must do something about it.” (Davaadorj U, written communication, July 2003.) As the Strategic Approach progresses beyond assessment to dissemination, service delivery research, and scaling up of successful innovations, it provides opportunities for observing concrete results under realistic conditions. This has stimulated further interest in its application to other areas of reproductive health and to other regions of the world.
Diffusion and sustainability of an innovation are enhanced when innovations are easy to install and comprehend, a claim that is both self-evident and supported by extensive evidence.26 The Strategic Approach may encounter difficulties in this regard because it is not easy to implement. Its costs, direct and, particularly, indirect, can be high25 because of the immense gap between the amount of change needed and the characteristics of the settings in which the approach is implemented. The approach requires time, initiative, and dedication.
Program managers often are eager to adopt a new process because of its apparent relevance and benefits. However, initial eagerness has not always been reflected in the ability to work in new ways. Several aspects of the Strategic Approach are, at least initially, not compatible with the established norms, values, and procedures of those who adopt it. Senior leaders in government are often not accustomed to working in a participatory manner, particularly with institutions outside the health sector. In Vietnam, the Ministry of Health did not initially recognize the Vietnam Women’s Union as a partner in strategy development. Effective implementation of the Strategic Approach requires unlearning old ways of organizational interaction and replacing them with new ones. This is not an easy process.
The challenges faced by public sector health systems in developing countries are often compounded by insufficient human resources and personnel policies that do not promote stability, which often results in rapidly changing program leadership and weakened technical capacity at all levels. For example, in a pilot project in Myanmar that seeks to strengthen district health services, most senior team members are rotated to a different district every 2 years. In both Brazil and Bolivia, there are often major turnovers in health teams after elections and as a result of other political changes. One municipality in Brazil, where projects had already been implemented, saw 7 new health secretaries in a period of 4 years.33 In such environments, long-term vision and planning are difficult, and the sustainability of innovations is endangered.
Many health systems are struggling to adjust to newly mandated processes of decentralization.34,35 The scaling up of successful innovations is often rendered more difficult when state and federal institutions become solely responsible for setting broad policy and standards but do not control budgets or determine local priorities for program implementation. For example, in Vietnam, the scaling-up strategy for supporting quality of care in family planning services began in the context of a strong hierarchical political system, but the strategy became less effective when decentralization placed responsibility for funding and programmatic decisions in the hands of provincial and district managers.30 For the same reasons, the scaling up of an innovative training approach in Brazil had to proceed municipality by municipality.36 There are no state- or federal-level institutions that support training in family planning and related aspects of reproductive health.
An important factor in countries’ decisions to implement the Strategic Approach has been related to the opening of policy windows—political opportunities that call for, or are receptive to, new directions in policy and program development.37 However, policy windows tend to be open for relatively short periods of time; the Strategic Approach initiates an institution-building process that typically stretches over several years. When policy windows close, the sustainability of the Strategic Approach process and its results may be threatened.
One of the most important reasons why the Strategic Approach has had success is the initiative of key individuals who have pushed its implementation forward. Even among organizations characterized by weak capacity, it can be possible to identify 1 or more policy entrepreneurs or champions who are open to new approaches and who can provide strong leadership.38 These individuals are able to give visibility to critical health issues and act on them.
In 1994, the newly elected Bolivian government allowed a policy emphasis on reproductive health, including family planning, which had been taboo for many years. The head of the Women’s Health Bureau had participated in the 1994 International Conference on Population and Development and recognized the Strategic Approach as a valuable tool for focusing policy debate on reproductive health and for leading governments and other agencies to appropriate actions. The role of such national innovators has been immensely valuable. However, the regular turnover of professional staff in leadership positions at all levels has meant that the window of opportunity for working with such champions is often relatively short.18,33 This explains why activities in some countries have not progressed through all 3 stages.
External facilitators have played an important role by preparing national teams to use the new methodology and supporting the voice of internal innovators. Facilitators have been critical in ensuring that there are participatory processes so that power differentials, e.g., between program managers and representatives of women’s or youth groups, do not inhibit equitable participation in the process. Furthermore, external facilitators provide technical input and share the experiences of other countries tackling similar challenges, thereby helping national teams develop innovative strategies.
The Strategic Approach is an innovation for policy and program development that has produced beneficial results in a growing number of developing countries. It builds on principles of strategic planning and organization development16,39 as it seeks to facilitate the implementation of quality reproductive health services that support the attainment of equitable access, reproductive health and rights, and gender equity. Although initially designed to facilitate the introduction of contraceptive methods, many countries have successfully adapted the approach to improve diverse areas of reproductive health. The methodology has much potential for application to other areas and is not specific to reproductive health. The participatory approach, the client-centered systems framework, and the phased implementation with explicit attention to scaling up successful innovations could make an important contribution to policy and program development in other areas of public health. This broader use would require additional adaptation and support from experienced facilitators.
Diffusion of the Strategic Approach can occur rapidly when national leaders have an opportunity to learn about the methodology. However, implementation is neither rapid nor simple. Because of the diversity of national environmental settings and the specific circumstances under which the Strategic Approach is implemented, the pace of its diffusion and success is highly variable. Thus, in some countries the process has moved through all 3 stages successfully, but in others it has progressed more slowly or stalled. The greater the needed change, the slower the process. The Strategic Approach is not an innovation that spreads spontaneously—it is an innovation that requires careful nurturing and support from both innovators within the country and international institutions. Where such support has been rallied, the results have been well worth the effort.
FIGURE 1— The Strategic Approach implementation process. FIGURE 2— Systems framework for guiding the Strategic Approach: Social, cultural, economic, and political contexts.
Focus Strategic Assessment of Needs, Year Service Delivery Research Scale Up of Successful Innovations Contraceptive introduction and quality of care for family planning Brazil, 1993 X X Vietnam, 1994 X X South Africa, 1994 X X Zambia, 1995 X X Myanmar, 1996 X X Chile, 1996 X X Chongqing, China, 2000
Oman, 2004X X Maternal mortality and family planning Bolivia, 1994
Dominican Republic, 2001
Guatemala, 2001X X Nepal, 2003-2004
Paraguay, 2004X X Adolescent health Kyrgyzstan, 1999 Prevention of unsafe abortions Viet Nam, 1997 X X Romania, 2001 X Mongolia, 2003
Ghana, 2005
Moldova, 2005X X Reproductive tract infections Latvia, 2000 X Ghana, 2001 X Brazil, 2002 X X China, 2002 X X Kosovo, 2004 X HIV/AIDS Brazil, 2001 X Cervical cancer Bolivia, 2002
Uttar Pradesh, India, 2004X Reproductive health Burkina Faso, 1996 Ethiopia, 1997 X X Myanmar, 1998 X X Lao PDR, 1999 X Yunnan, China, 2002
Rajasthan, India, 2004X 
A great many people have contributed to the development and evolution of the Strategic Approach since its inception during the early 1990s. The Strategic Approach has succeeded in the many countries where it has been implemented because of the strong support of key policymakers, program managers, donor organizations, and participants from nongovernmental organizations, women’s organizations, research institutions, and international agencies. The authors thankfully acknowledge the essential contributions of national team members and the many service providers, community leaders, and local women and men who shared their experiences and points of view throughout the implementation process. The authors recognize with appreciation the strong and continuing efforts provided by the network of Strategic Approach partners, whose dedication has helped make the approach successful. Finally, the authors extend appreciation to Nancy Newton for her editorial support and to Max Heirich for reviewing drafts of this article.
Human Participant Protection No protocol approval was needed for this study.
