Using a Systems-Based Logframe for Health Systems Strengthening

A project logical framework is often used as the core reference document for project design, approval and evaluation. However, too often project logframes are a barely legible, fine-printed document buried somewhere in the annexes. But when used properly, a logframe can provide a tool to guide project design, facilitate discussions with partner agencies, and contribute to systems strengthening.

One of the reasons some projects have little success in capacity building at the health services delivery area is that most of the project objectives and indicators are defined in terms of supporting activities managed by different MOH offices at the central level. While considerable progress can be made in capacity-building at the national level, this usually ends up reinforcing existing centralized MOH management capacity. As a result, evaluations often find that a health district capacity-building project has had almost no impact the improvement of the provision and management of health services at the health center and community levels.

One strategy to resolve this problem is to focus (or re-focus an existing project) to strengthen service delivery and support components for communities, health centers and health districts. The use of a systems-based logframe can facilitate this process because it:

links the outputs of the logframe to health system support components;
provides a complete overview of the project;
links the logframe outputs to the written sections of the project description;
provides a framework within which to brainstorm objectives and indicators;
is a concise document for distribution and discussion with partner agencies;
makes the writing of the project paper easier to manage; and
provides a handy reference document for monitoring project progress.

Two examples of actual health systems logframes are provided.

1) The Promoting Health Interventions for Child Survival (PHICS) project in Malawi (see below) which was refocused to redirect more project resources to the health district level.

2) The Maternal Child Health/ Family Planning Project which was designed (in French) using a systems-based logframe approach.

EXAMPLE OF A SYSTEMS-BASED LOGICAL FRAMEWORK

(from the Promoting Health Interventions for Child Survival project in Malawi)

Narrative Summary	Objectively Verifiable Indicators	Means of Verification	Important Assumptions
I. Goal: Improve health status..	Decrease infant mortality from 154 in '88 to 100/1000 by 1997	DHS surveys, '92 & '97	Economic, political stability
II. Purpose: Increase the institutional capacity to deliver and sustain health services	80% districts are functional 50% of health centers have improved services 80% of priority diseases are properly diagnosed, treated and counseled	District reports,	MOH remains dedicated to decentralization Key district personnel remain stable
III. Outputs: A. Planning & Management: Districts are effectively managing and coordinating PHC services	80% of districts have well defined boundaries, functional management teams, written action plans, regular HMIS reporting, and local budget management.	District reports, maps, supervision reports, committee minutes, site visits	MOH policy provides regional & district authority to review/revise boundaries
B. Logistics- Supervision and Supply Line: District have a functioning system of vehicle maintenance and repair facilities...,	80% of health centers possess basic equipment, medicines and materials < 25% vehicles are immobilized. 70% of centers supervised each mo.	District reports, supervision visits, site visits	Timely procurement of equipment, meds & supplies at the national level.
C. Sustainability: Financial sustainability of PHC will be increased through cost sharing and community financing of health services. Management sustainability will be improved by decentralized management of budgetary resources allocated to Districts & health centers.	Pilot testing of cost sharing mechanisms in selected Districts is covering the resupply of medicines in 50% of participating health centers. 50% of project-assisted districts prepare and manage their own budgets, including clear identification of budgetary support from all sources.	Health center financial reports budgets and financial reports	The MOH authorizes testing of cost sharing for Districts. Districts have and use the authority to prepare and manage their own budgets.
Narrative Summary	Objectively Verifiable Indicators	Means of Verification	Important Assumptions
D. Health Management Information Systems: Decentralized Health Information systems will be functional at all health system levels providing information on health status and PHC/CS services, and encouraging local analysis and decision-making.	80% of project district HMIS reports are received by the region with no more than a month delay. 50% of project Districts and health centers analyze service statistics monthly, study trends, and use results for decision-making.	HIS, HMIS, & District reports District reports, site visits	Personnel, equipment and programming resources are adequately supported by the national level.
E. Health Education: IEC programs by districts have been reinforced and expanded with emphasis on interpersonal communications for child survival	80% of health centers in project Districts have IEC materials and methods for principal PHC/CS program interventions. 50% of health centers in project districts have IEC schedules/plans demonstrating a balance of topics and methods. 70% of IEC sessions are completed as planned.	District reports, supervision visits Site visits
F. Research: Districts have improved the quality of program interventions, support components, or community development through operations research. Research in priority diseases, including malaria, diarrhea and ARI, has improved prevention and control at the service provider level.	Each project year 50% of assisted Districts complete one OR activity related to program interventions, support components, or community development. A national PHC/CS conference is held annually exchange lessons learned and disseminate OR results. Five Applied/OR projects for improved approaches in priority disease prevention and control are completed in collaboration with Districts. Improved algorithms for integrated treatment of the sick child are being used in 25% of health centers of project-assisted Districts	OR reports, RU database Conference report Research reports, site visits Research reports, District reports, site visits, QA	The Mangochi research station is completed in '94. Research grants to NGOs are made in 1994.
Narrative Summary	Objectively Verifiable Indicators	Means of Verification	Important Assumptions
G. Community Development: Village health committees are active in planning, managing and financing health and development initiatives.	50% of communities with HSAs have a health committee or women's group which have successfully completed a community development project that includes participation by women in planning & management.	health area plans, supervision	Cultural factors permit participation of women in development activities
H. Training: In-Service Training (regional & District) has improved the quality of management teams, health center personnel, and HSAs/CBHWs. Pre-Service Training of District personnel has been strengthened in PHC management.	75% of assisted District teams are trained in planning & management, child survival, health education, case management, supervision, and Operations Research. 75% of the health center catchment communities have an equipped, operational, and supervised HSA/CBHWs. 75% of pre-service health training institutions are using PHC management training modules. 80% of health personnel complete a District based practicum before the end of their studies.	Training reports District reports, supervision visits Curricula review, site visits training reports	LSHS/GOM relationship revised so LSHS is functional and effective.