Situation Analysis

Description

Situation analysis is a tool for examining the availability and quality of family planning and reproductive health services. The methodology has four essential objectives: (1) to describe the potential of current policies and programme standards to deliver quality services; (2) to describe the capacity of service delivery staff and facilities to provide quality services to clients and compare them with policy and programme standards; and (3) to describe the actual quality of care received by clients. Multiple situation analyses have been used to determine programme trends over time (Hong, et al., 2005).

Key Elements

STRENGTHS OF THE TOOL Although situation analysis borrows from other methodologies, it integrates a number of approaches to family planning and reproductive health. These include:

• a systems perspective for identifying crucial subsystem components of 
   programme operation;

• visits to a large sample of service delivery points (SDPs) rather than visits to only a 
   few SDPs or reliance on expert opinion;

• a client-oriented focus on quality of care;

• structured interviews with managers, providers, and clients, rather than with community 
   informants as with the Demographic and Health Survey (DHS) availability module;

• recording of clinic facilities, equipment and commodities available on the day of the 
   research team’s visit; and

• nonparticipant direct observation of all family planning client-provider interactions on 
   the day of the visit.

Situation analysis emphasizes the collection of data on quality by trained observers, especially the important components of family planning counselling. In separate studies, researchers have determined that such observation data are relatively reliable (Huntington et al., 1996), and while it may be somewhat positively biased, it is probably of greater validity than client reports (Ndhlovu, 1998).

Situation analysis results have proved useful for a variety of purposes in administrative decision-making. These included conducting problem-solving discussions among various levels of programme managers; ordering or redistributing equipment; redesigning and reorienting training programmes; redesigning staff deployment plans to respond to actual case loads; redesigning technical assistance programmes; and documenting and representing programme needs, such as missing equipment, to donor agencies.

An attractive feature of the methodology is its very simple and graphic reporting on results, which is easily understandable to people without advanced statistical training, like many programme managers.

LIMITATIONS OF THE TOOL Limitations of Situation Analysis include its relatively high cost and substantial time required; the possible need for technical assistance to train field workers and analyse data; difficulties involved in weighting of data, and some possible issues in the reliability and validity of observations and interview responses.

Principles and Steps for Using the Tool

PARTNERS Situation Analysis studies should only be conducted with the full participation of the administrative leadership and staff of the programme under review. They are the people best positioned to know what issues are important in the local context and they are the ones who will be in a position to use the data to improve their programme. These partnerships are best formed at the initial stages of planning the study. If possible even busy managers should be encouraged to see the study in operation in the field. And programme managers should receive early results of the study and participate in selection of the findings to be included in the dissemination process. Service delivery staff should be involved in interpreting the data.

TARGETS Situation analysis targets service delivery points of all types, including clinics, health centres and hospitals, and the clients utilizing services. Studies can also include specialized service units such as HIV testing or treatment centres, free-standing family planning clinics run by NGOs, abortion facilities, or other stand-alone services. Service delivery points serve as the sampling unit. However, the study also targets for interviews with providers, including community-based workers, and clients at service delivery points.

The situation analysis methodology and its uses have evolved considerably since the first such study was conducted in Kenya in 1989 (see below) (Miller et al., 1992). However, no matter what the purposes of the study are, all situation analysis studies are intended to discover and highlight problems in service delivery. Thus, the methodology is often coupled with operations research and technical assistance to devise strategies for solving the problems identified in the study. Another similarity is that all studies rely on the same four basic approaches to data collection, including:

• An inventory of equipment, supplies and services at service delivery points;

• Observations of provider-client interactions in the various services under review;

• Exit interviews with observed clients; and

• Interviews with providers.

METHODOLOGY Situation analysis attempts to include either a representative sample of all service delivery points in a large geographical area such as the nation, or all service delivery points in a smaller area, for example the Nairobi City Commission Clinics (Mensch et al., 1994). The sample studied is usually between 100 and 400, and depending on the total number of service delivery points, resources available for the study, and its purpose. Sampling is stratified, in two stages. The first stage is to sample by province or some other geographic area with probability of selection proportional to the number of service delivery points contained in the geographic area. The second stage is to sample by type of service delivery point, with a special emphasis on hospitals which often serve the largest number 
of clients.

Weighting of service delivery points can be an issue in situation analysis studies. Small clinics should not generally receive the same weight in analysis as large hospitals with many staff and clients. The methodology calls for observation of all clients who come to the service delivery point on the day of the researchers’ visit, but this is not possible for large hospitals. For most service delivery points no weight is necessary because the observed clients constitute a census. But for hospitals, no weight is possible because there is no information on the universe of clients on the day of the visit. The same argument holds for the family planning client exit interviews. The solution is to make sure that in each geographical area the one district hospital and the two or three health centres are 
included, and then randomly choose the rest of the sample from the list of clinics with 
equal probability.

TIME REQUIRED Depending of the purposes and size of the planned study, situation analysis studies typically require 8-12 months. This includes 1-2 months for reviewing and adjusting instruments to the local context, one month (more likely 2-3 weeks) for training fieldworkers, 1-2 months for data collection (depending on the number of data collection teams trained), and 3-5 months for data input, analysis, write-up and dissemination.

HUMAN RESOURCES The managers and monitoring and evaluation staff of reproductive health and family planning programmes can usually adjust existing instruments to local contexts, especially if they can call on technical assistance when they need it. Studies of 100 service delivery points require about five teams of at least three, to observe provider-client interactions, to conduct the inventory of sites, and to interview clients. Nurses have proved adept at these tasks. Data analysis calls for a small team of experts, ideally including some at doctoral level.

Ethical considerations include informed consent discussions with potential participants about the purposes, risks, and benefits of participation; assurance of privacy and confidentiality; ethical review in line with national laws and practices.

BUDGET LINE ITEMS The budgets for conducting a situation analysis have varied from $35,000 for the Nairobi City Commission study in the 1990s to more than $200,000 in more recent national studies in Ghana, and in the KwaZulu Natal Province of South Africa. 
Major expenses for such studies include:

• Photocopying costs for a large number of copies of several different instruments.

• Salaries and per diem allowances for 15 or more fieldworkers for two weeks of training 
   and one month of fieldwork.

• Salary and per diem allowances for 1-2 fieldwork supervisors.

• Salary for data input personnel (at least two) for approximately one month.

• Salary for data analysts.

• Training venue.

• Food, tea or coffee during training.

• Cost of a dissemination seminar.

• Vehicle rental (if necessary) and petrol.

Adaptation and Technical Assistance

EXPERIENCE WITH THE TOOL Situation analysis methodology has been used in scores of different studies to document the availability and quality of a wide array of reproductive health services in many different countries on all the continents. These include, for example: a review of all maternal and child health services in Botswana (Maggwa et al., 1996); an expansion of reproductive health services in public service delivery points in Vietnam (Nhan, et al., 2000); a study of the extent to which HIV/AIDS education and services were integrated into reproductive health services in KwaZulu Natal Province of South Africa (Ndhlovu, et al., 2003), and the use of contraception in post-partum, post-abortion, and programmes for prevention of mother-to-child HIV transmission in Nicaragua (2008). An early study by Mensch et. al. linked a situation analysis study to the DHS study in Peru to assess the impact of the quality of family planning services on contraceptive use in Peru. Results from 11 country studies in Sub-Saharan Africa were used to compare and contrast availability of and access to services, service delivery 
point readiness (staffing and training, equipment, methods offered, and supplies); urban versus rural services; quality of care, and changes in programmes over time (Miller et 
al, 1992). Three situation analysis-type studies were used to gauge the extent to which 
the family planning programme in Ghana had changed over the decade1993-2002 
(Hong et al., 2005).

RECOMMENDATIONS FOR ADAPTATION

• Keep the study as simple as possible.

• Include only questions that will be useful for administrative and other decision-making.

• Focus on the highest-priority sexual and reproductive health services.

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

POSSIBILITIES FOR TECHNICAL ASSISTANCE AND CONTACT INFORMATION 
The Population Council has supplied technical assistance to many Situation Analysis studies. Contact Ms. SunAe Lee (slee@popcouncil.org), or Dr. John Townsend (jtownsend@popcouncil.org). UNFPA staff have frequently helped carry out these studies, especially in the Arab states.

References

Bruce, J. 1990. “Fundamental elements of the quality of care: a simple framework.” Studies in Family Planning, 21,2:61- 91.

Hong, Rathavuth, Nancy Fronzak, Amanua Chinbuah, and Robert Miller, 2005. “Ghana Trend Analysis for Family Planning Services, 1993, 1996, and 2002.” DHS Trend Reports No. 1, ORC Macro, Calverton, Maryland USA.

Huntington, D., K. Miller, and B. Mensch. 1996. “The reliability of the Situation Analysis observation guide.” Studies in Family Planning, 27,5:277 - 282.

Maggwa, Baker Ndugga, Robert A. Miller, Benjamin Baakile, and Lucy Maribe. 1996. A Situation Analysis of the Maternal and Child Health/Family Planning (MCH/FP) Program in Botswana. MCH/FP Unit, Family Health Division, Ministry of Health, Gaborone, Botswana and The Population Council, Nairobi, Kenya. A shorter version appears also in African Journal of Fertility Sexuality and Reproductive Health, 1:2, December.

Mensch, Barbara, Mary Arends-Kuenning, and Anrudh Jain, 1994. “Assessing the impact of the quality of family planning services on contraceptive use in Peru: A case study linking situation analysis data to the DHS,” Policy Research Division Working Paper no. 67. New York: Population Council.

Mensch, Barbara, Robert Miller, Andrew Fisher, John Mwita, Nelson Keyonzo, F.Y. Mohamed Ali, and Cecilia Ndeti. 1994. “Family planning services in Nairobi: a situation analysis of city commission clinics.” International Family Planning Perspectives.

Miller, R.A., L. Ndhlovu, M. Gachara, A.A. Fisher. 1992. “A Situation Analysis of the family planning program of Kenya,” in Jain, A., ed. Managing Quality of Care in Population Programs. Kumarian Press, New York. Also appears as Miller, R.A., L. Ndhlovu, M. Gachara, A.A. Fisher. 1991. “The situation analysis study in Kenya.” Studies in Family Planning 22(3).

Ndhlovu, L. 1998. “Lessons learned from Situation Analysis studies in Africa.” Paper presented at the Annual Meeting of the Population Association of America, Chicago.

Ndhlovu, Lewis, Catherine Searle, Robert Miller, Andrew Fisher, Ester Snyman, Nancy Sloan, 2003. Reproductive Health Services in KwaZulu Natal, South Africa: A Situation Analysis Study

Focusing on HIV/AIDS Services, Population Council and KwaZulu Natal Department of Health, Washington, D.C.

Nhan, Vu Quy, Le Thi Phuong Mai, Nguyen Trong Hau, Robert A. Miller, Thomas T. Kane, John Stoeckel, Lynellyn D. Long, Bui Thi Thu Ha, Chu Phuc Thi, Nguyen Thi Thom. 2000. 
A Stituation Analysis of Public Sector Reproductive Health Services in Seven Provinces of Vietnam. Prepared for Ministry of Health, and UNFPA, The Population Council, Hanoi.

 

Solis, et. al., 2008. Situation Analysis of the Use of Contraception in Postpartum, Postabortion, and Prevention of Mother-to-Child HIV Transmission (PMTCT) Programs.Population Council’s Frontiers Project.http://www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Nicaragua_FP.pdf