Understanding

Fundamental Concepts
 Systems
■ A system is the combination of interacting
components operating within a boundary
for a specified purpose

■ It receives inputs from the environment,

transforms them and sends them back into
the environment as its outputs
 System thinking
■ Any given system cannot be understood by
the separate knowledge of its single
components

■ Systems can only be understood through the

knowledge of all the components and, even
more important, of their interactions
 System thinking
■ Everything affects everything else

■ Nothing can stand on its own or be understood on

its own

■ Everything is part of a greater entity

■ Any action affecting one component, affects all

other components of the system (although with
different degrees of importance)
 Sustainability
■ The capacity of a system to remain operational after the
withdrawal of external support

■ The capacity of a system to function effectively over time

with a minimum of external input (SCF)

■ There are different aspects of sustainability:

■ Financial
■ Political
■ Technical
■ Others …

■ At the end of the day… sustainable is what we decide to

sustain
 Opportunity cost

■ The value of the next best alternative or

opportunity which has to be foregone in
order to achieve a particular objective,
produce or purchase a given good or service
 Equality
■ The absence of differences in conditions, or
treatment among populations or groups defined

■ Socially

■ Economically

■ Demographically

■ Geographically
 Equity
■ The absence of avoidable or remediable
differences among populations or groups defined

■ Socially

■ Economically

■ Demographically

■ Geographically
(World Health Organization)
 Allocative Efficiency
■ The capacity of a system to distribute resources among
competing activities, in a way that no alternative reallocation
offers improvements in returns

■ Related to comparative efficacy of interventions and priority

setting

■ An aggregate concept, referring to competing options, inside

or outside the health sector, and to the scale of programmes

■ Allocative efficiency assumes that competing options work at

the same level of technical efficiency
 Technical efficiency
■ Maximising output for a given set of
physical inputs, or minimizing the physical
inputs required to produce a given output

■ (Hensher M. Financing Health Systems

through Efficiency Gains. CMH Working
Papers Series. Paper No. WG3: 2. 2001)
 Mission

■ The purpose and philosphy of a given organisation

■ The reason why it exists

■ e.g., the stated mission of the Ministry of Health is

to improve the health status of the population
 Goal
■ A broad statement of intention, a long term
accomplishment towards which
programmes and services are directed

■ It must be consistent with the Mission. e.g.,

HFA 2000
 Aim
■ The broad statement of a desired
achievement in relation to a given goal and
specific to a particular problem (for
instance, to improve the nutritional status of
<5 children)
 Objective
■ A measurable amount of progress contributing to
the achievement of a given goal

■ Some authors introduced the acronym SMART to

stress the main characteristics of well formulated
objectives:
■ S pecific
■ M easurable
■ A ttainable
■ R elevant
■ T ime-bound
 Strategy
■ A broad approach adopted to achieve goals and
objectives

■ For instance, to increase immunisation coverage,

one can adopt the strategy of mobile services

■ to improve the nutritional status of a given

population on can adopt the strategy of health
education or promotion of income generating
activities
 Planning
■ Making informed decisions about future
courses of action intended to achieve clear
objectives within a specified period of time,
with the resources available now and in the
future

■ A systematic attempt to ensure that the

resources available now and in the future
are used in the most efficient way to obtain
explicit objectives
 Allocative Planning

■ Deciding on how to allocate scarce resources

to different sectors, activities, departments,
etc., according to clear, clarified,
transparent criteria
 Activity Planning

■ Setting of monitorable timetables and

schedules for the implementation of
activities meant to achieve objectives
 Plan
■ Description of:

■ objectives,

■ activities designed to achieve them,

■ people responsible for their implementation

■ time-span within which they have to be implemented

■ the resources needed and their sources

■ indicators for monitoring and evaluation

 Strategic Plan

■ A plan dealing with broad issues and

addressing them in the medium and long
term (5, 10 years or even more)

■ It indicates the direction a given

organisation intends to follow in the
medium to long term
 Business Plan

■ A strategic plan indicating the direction a

given organisation intends to follow and
providing income and expenditure
projections
 Operational Plan

■ An activity plan detailing precise timing and

mode of implementation
 Workplan
■ An operational plan referring to a small unit

■ The organised and detailed description of activities to be

carried out to achieve predetermined objectives in the short
term (for example one year or less)

■ For each activity, the following aspects should always be

specified:

■ 1) The objective (results) to be achieved

■ 2) When it should be carried out
■ 3) Where
■ 4) By whom (who is responsible for what)
■ 5) How much will it cost
■ 6) Where will the needed funds come from
■ 7) Monitoring and evaluation indicators
 Project
■ A set of planned actions designed to bring
about desired changes in a previously
analysed situation by achieving well
identified objectives using well identified
identified resources in a defined period of
time

■ Achievements and setbacks should be

assessed by using a set of well defined
indicators for monitoring and evaluation
 Target
■ A step on the way to achieve an objective

■ It measures the amount of output to be

obtained with a given activity in a specific
period of time (usually a fraction of the time
set to achieve the related objective)
 Activity

■ Specific work to be done to obtain a given

objective

■ A group of tasks
 Task

■ Work to be carried out within a certain time

■ One element of an activity

Logical Framework Analysis (Logframe)
■ A method of project or programme planning using a
matrix of the goal, purpose, expected results and activities
on the vertical axis and the performanc indicators, means
of verification and assumptions on the horizontal axis

■ The approach is often conducted in a group setting with

facilitation so as to promoteteamwork and ownership of
the plan

■ The matrix can also be used for monitoring and evaluation

and may be updated in response to changes in the
timetable, performance, or feasibility of
componentactivities

■ Logframe planning is favoured by some international

development agencies (Last 2001, modified)
 Matrix
■ In epidemiology and biostatistics, a display
of data in columns and rows
 Input

■ Resources used (or needed) to implement a

given activity (human, financial, material
time)
 Output

■ The measurable product of an activity or a

set of activities (for instance, the number of
children immunised)
 Efficiency

■ The measure of how economically resources

are utilised to achieve predetermined
objectives

■ The ratio of inputs over outputs

 Effectiveness

■ The degree of attainment of predetermined

objectives
 Monitoring
■ The continuous observation and measurement of
implementation to make sure that it is going
according to plans

■ If monitoring reveals that there are problems or

discrepancies between implementation and plans,
corrective actions must be taken to bring activities
back on track

■ In some circumstances, it may be necessary to

revise the plans
 Evaluation
■ The attempt to determine, as systematically
and objectively as possible, the relevance,
efficiency, effectiveness, outcomes and
impact of activities in the light of their
objectives

■ It must consider the inputs, the process of

their transformation in outputs, the
outcome and the impact
 Outcome

■ The end result of an activity or a set of

activities (for instance, decreased incidence
of measles after an immunisation
campaign).
 Impact

■ Long term, lasting change produced upon a

given situation by a set of activities or events
(for instance, decreased infant mortality)
 Quality

■ The measure of how good something is

■ Doing the right things right, at the right

time, in the right place, with the right
resources
 Standard

■ Criterion, measure, against which to

compare weights, lengths, quality, purity,
etc.

■ Required, expected, accepted level of quality

 Quality Assurance
■ The continuous, systematic process to
ensure that
■ the right things are done
■ to achieve the right objectives
■ at the right time
■ in the right place
■ by the right people
■ in the right way
■ with the right resources
 Gini Coefficient
■ A measure of the extent to which the
distribution of income (or, in some cases,
consumption expenditures) among
individuals or households within an
economy deviates from a perfectly equal
distribution

■ The coefficient ranges from 0—meaning

perfect equality—to 1—complete inequality
 The Planning Questions
■ Where are we?
■ Why are we here?
■ How did we come to be here?
■ Should we stay here?
■ Where would we like to be?
■ How shall we get there?
■ What must we do to get there?
■ When shall we get there?
■ What may stop us from getting there?
■ How shall we know we are going there?
■ How shall we know we got there?
■ Once there, should we stay there?
 Where Are We?
■ Is analysing the current situation
■ Describing the situation in terms of
■ What?
■ Who?
■ Where?
■ How many?
■ When?

■ Example: 47% of children under 5 years in

Nkozimania have Protein-Energy Malnutrition
 Why Are We Here?(1)
How Did We Come To Be Here?
■ Try to analyse:
■ The causes (where possible)
■ What went wrong?
■ Factors that favoured the development of the situation
■ Did we choose to be here?
■ Was the situation inevitable?
■ Could we have been elsewhere?

■ Example: Prolonged drought for 1 year has led to poor

harvests and food insecurity in Nkozimania
 Why Are We Here?(2)
How Did We Come To Be Here?
■ Knowing the nature and the cause helps to
know whether the problem is ‘yours’
■ Your direct responsibility
■ Only you alone can address it
■ Need for inter-sectoral action
 Should We Stay Here?
■ Is a managerial question
■ Is being proactive
■ Do you wish to change?
■ Why should you change the situation?
■ Justify the intended change
■ What are the consequences of staying here?
■ What are the consequences of changing?
 Where Would We Like To Be?
■ Vision
■ Mission
■ Goal
■ Aim / Purpose
■ Objectives
■ Targets
 How Shall We Get There?
What Must We Do To Get There?
■ Strategies
■ Examples:
■ Health education
■ Irrigation
■ Food storage
■ Food preparation
■ Nutritional rehabilitation

■ Activities
 When Shall We Get There?
When Do We Want To Be There?
■ Time frame / Timeline
■ Time-binding
■ Sets time in which to evaluate progress
What May Stop Us From Getting There?

■ Do a SWOT analysis
■ Strengths
■ Weaknesses
■ Opportunities
■ Threats
■ Analyse resources
■ Plan realistically
■ Analyse stakeholders
■ Environmental scanning
How Shall We Know We Are Going
There?
How Shall We Know We Are Going There?
■ Plan to Monitor and Evaluate the process
■ Monitoring is continuous, day by day (movie)
■ Evaluation (snapshots)
■ Formative
■ Process
■ Summative
■ Develop Indicators
■ Process Indicators (Milestones)
■ Outcome Indicators
 Indicators (1)
■ Marker of change in the situation
■ Baseline
■ Process
■ Output
■ Outcome
■ Impact
■ Usually numerical, but one should also have
qualitative indicators
 Indicators (2)
SPICED:
■ Subjective: Topical, specific to what is being measure
■ Participatory: Better if they are agreed upon at design
stage
■ Indirect
■ Cross-checked
■ Empowering
■ Diverse
How Shall We Know We Got There?
■ Use of Indicators
■ Summative Evaluation
 Do We Want To Stay There?
■ Re-assess the situation
■ Are you satisfied with the situation?
■ Are there new needs to be addressed?
■ Decide if you need to change
■ Plan again for the new changes
 The Planning Spiral (3)
Situation
Analysis
Reassessment Priority setting

Evaluation Monitoring & Option appraisal

Evaluation

Implementation Setting goals, objectives

Making
a work
plan
 Situation Analysis (1)
■ Data requirements
■ Data sources
■ Assumptions
■ Baseline Surveys
■ Analysis of available data
■ Assess the gap between ‘What is’ and ‘What
should be’ i.e. ‘the problem’
 Situation Analysis (2)
■ How do you recognise that a problem is a
problem?
■ Mortality
■ Morbidity
■ Situation is not what it should be (judging from
standards, expectations, trends, comparison with
others etc)
■ Complaints and reports
■ All senses are used
 Priority-Setting
■ Making choices
■ Refer to the vision and mission statement
■ Scarce resources vs. endless needs
■ Only what is absolutely necessary
■ Methods:
■ Economic Evaluation e.g. CBA, CEA
■ Multivariable Decision Matrix
■ Delphi Technique
■ Nominal Group Technique
 Option Appraisal (1)
■ Choose the most:
■ Appropriate for the need
■ Feasible (technical, administrative)
■ Affordable (financial, personnel, time)
■ Acceptable (politically, culturally)
 Option Appraisal (2)
■ Methods
■ ‘Weeding out’
■ Strategic questions
■ Key factors
■ Flow charts
■ Key decision clusters
■ Cost-Benefit analysis
 Setting Goals
■ Look at Vision and Mission Statement
■ Select a goal that is achievable in the long-term
■ Goal should be socially beneficial
■ NB: Your activities only contribute to the
realisation of the goal
 Choosing Strategies
■ Choose a feasible strategy that will lead to the
realisation of the goal.
■ Look at the available means (4 Ms)
■ Money
■ Manpower (Human resources)
■ Materials
■ Minutes (Time)
■ Look at current trends of doing things
 Setting Objectives
■ SMARTER
■ Specific: Cannot be confused with anything else
■ Measurable: Have clear identifiable output units
■ Achievable: Feasible
■ Realistic: Consider available resources
■ Time-bound: Set time for review of progress
■ Enjoyable: Beneficial to the target population
■ Rewarding: Beneficial to the implementers
 The Work-plan
■ Schedule of work indicating
■ What is to be done
■ Why is it to be done
■ When is it to be done
■ Who is to do it
■ What resources are to be used
■ Where will they come from
■ How to know that it’s being done
■ Assumptions made
 The Gantt Chart
■ A chronological order of planned activities
■ Helps to:
■ Identify all activities to be done, including
administrative procedures
■ Identify concurrent activities so as to plan for them
without straining available resources
 An Over-simplified Gantt Chart
Activity Responsible Timing
person
J F M A M J

Prepare Health Team x x

workplan
Implement Health Team x x x x
project
Evaluate x x
project
Monitoring, Evaluation, Reassessment
and Situation Analysis
■ Monitoring:
■ Continuous process of Evaluation.
■ Equal to Formative and Process Evaluation.
■ Less formal
■ Evaluation:
■ Formal review of progress of plan implementation
against the pre-set targets
■ Usually pre-determined: Formative, Process and
Summative
Monitoring, Evaluation, Reassessment
and Situation Analysis
■ Re-assessment:
■ Analysis of situation after implementation of
plan to see if:
■ There was any change in previous situation
■ Any change was due to the intervention taken
■ New plans or approaches need to be used
■ There was any lesson learned from previous
experience