Health Research Program

Process Documentation

Process documentation is an evaluation method to track meaningful events in projects or programs as they happen. This provides staff and stakeholders with insights into how implementation processes are working, allowing for course corrections, program adaptation, and innovation, which together enhance the prospect of“Process documentation is a method of collection, collation, analysis and communication of experiences in contextually‐appropriate ways. This set of activities is guided by a certain programme logic or ‘theory of change’ (see TIP 7): a representation of the underlying ideas and assumptions about how change is expected and/or foreseen to take place in each initiative. Hence, process documentation is an attempt to identify and bring to the fore the factors that affect the change process that the initiative aims to contribute to, whether these factors were expected or otherwise. To be more effective, process documentation must be considered a shared effort across the full spectrum of project participants.” (da Silva 2011). program success and scale up. It may also help facilitate adaptation of program strategies and scaling up to other locations and contexts (Ross 2021). Process documentation should not capture everything that happens during program implementation but should include meaningful milestones that explain how and why a project or program made the decisions it did, and the subsequent outcomes associated with those decisions.

What is the value added of process documentation?

Process documentation is at the heart of implementation research (IR). By documenting the processes of implementation in real time, this method helps explain how and why interventions, strategies, and systems effect change. This information can then be used to clarify and adjust a project’s theory of change (See IR Tip #7). Process documentation contributes information and insights in parallel to implementation, allowing for mid-course corrections and improvement. Beyond ongoing improvements to a given intervention, it can provide deeper understanding for replication and scale-up. Process documentation is a good complement to routine monitoring that typically provides data on inputs and outputs, and to qualitative assessment that is often performed at the conclusion of a project. Implementation of any program can be influenced by context and interactions of factors such as motivations, attitudes, power, decision making, and willingness to change.As part of work to mitigate the potential effects of COVID-19 on RMNCH services, the USAID-funded MOMENTUM Knowledge Accelerator project reviewed available evidence from Ebola and Zika outbreaks. While RMNCH outcomes (e.g., antenatal care coverage, contraceptive use) and some supply and demand effects (availability of services, trust in community health workers) were documented, little description exists on what was done or how interventions or implementation strategies were changed to work better. We know that adaptations were often made, but without process documentation we cannot learn and extrapolate from what worked in what context and why (MOMENTUM 2020, Hirschhorn 2020). Process documentation can capture these more nuanced factors that may have an impact on program uptake and outcomes. In documenting perceptions, experiences, and changes as they happen from the multiple perspectives of those involved, process documentation contributes to a better understanding of what was done, what was changed, and why. The benefits of process documentation are not limited to the one program or intervention under study; dissemination of lessons learned can enrich similar efforts and increase the likelihood of success by pointing to context-specific missteps that may not be captured in standard monitoring and assessment findings.

Very simply, process documentation starts with a project’s theory of change or hypothesis (see IR Tip #7), and implementation strategy, and uses various tools—such as timelines, diaries, meeting notes, interviews, observations, dialogue, and videos—to document how change happens (or fails to). Process documentation captures a project’s major events and milestones, not every minute detail.

When to use process documentation

Process documentation should be considered when trying to deconstruct what is happening as a result of a program or intervention. It can help unpack how and why strategies do or do not work at every stage of an intervention, including the start-up phase when they are first introduced and tested, during implementation when adaptations are being made and improvement measured, and at the point of project maturation when strategies are disseminated, replicated, or scaled up. It can also support and improve responses to context or systems stressors such as those experienced with COVID-19.

Key questions for process documentation and prioritization

One challenge with process documentation is determining where to start and what to focus on, given the complexity of implementation in the real world and the limitations of time and resources.

If you are planning to conduct IR and process documentation prior to program implementation, the following questions can help guide your effort:

    • How is this program going to work? What is your theory of change/hypothesis and what are your operational assumptions?
    • Who are the program’s key stakeholders and what roles do they play in setting the agenda for the program?
    • How will you systematically capture information about what is actually happening relative to your theory of change? How will you track important assumptions?
    • How will you analyze and organize information so that all stakeholders can reflect on what is being learned and improve processes, during/throughout the intervention?

If you are conducing IR and process documentation for a program that is already underway, further questions to consider include:

    • What do you understand about what is happening now? What are the most important unknowns or questions that relate to how implementation is going?
    • Within the confines of resources and this understanding, and in consultation with stakeholders, what do you want to focus process documentation on now? Will the information:
        • Clarify appropriateness of underlying assumptions in the theory of change?
        • Explain progress related to a critical node on the pathway to outputs/outcomes (necessary step) in the current context?
        • Allow better and more rapid adjustments to implementation?
        • Allow for action on the information in the time available to the program or for later adoption

Using process documentation to assess and adapt the theory of change

Process documentation provides important information for reviewing the extent to which a program’s theory of change or logic model is aligned with what is actually happening in the field. Along with other monitoring and evaluation data, it can help staff and stakeholders reflect on assumptions, planned versus actual outputs, linkages between change steps, and alignment of progress with goals and outcomes. This can then inform decisions regarding program adaptation, innovation, and needed improvements (Peek 2019).

Steps to conduct process documentation

Process documentation needs to be integral to program or project plans and aligned with other monitoring and evaluation processes. It must be shaped by the theory of change or logic model (see IR Tip #7) which is guiding the intervention strategy. The following steps in Table 9.1 guide the development and application of process documentation (Nyangara 2015).

Table 9.1
Fig 9.1 How to keep a high-level timeline

Case studies

Case study 1: Kuboresha Afya Mitaani case study in Kenya (Bennett 2020)  
In the midst of change due to Covid-19 and the shift of health service management to a different government entity, the maternal and child health project – the USAID-funded Kuboresha Afya Mitaani project found process documentation allowed quicker and more strategic adaptation of activities. Ongoing stakeholder and decision maker mapping at multiple levels resulted in more effective engagement and progress through new requirements. The project has now built process data collection and collaboration on electronic platforms deepening participation and efficiency.

Case study 2: From research to national expansion: community-based management of childhood pneumonia in Nepal (Dawson 2008)  
In rural Nepal, local research was showing that community-based management of childhood pneumonia was highly effective. To scale up the intervention, the health system would need to engage female community health volunteers (FCHVs) in case management using oral antibiotics. A technical working group of government officials, local experts, and donor partners piloted two different models of delivery to determine whether this approach could be expanded nationally. The results were clear: community-based management of pneumonia by FCHVs doubled the total number of cases treated compared with areas served only by facilities. Process documentation was essential to explaining how and why this approach was so successful. Information on how implementation worked and the engagement of key decision makers in that process provided the foundation for rapidly moving delivery to national scale.


Key resources

da Silva Wells C, Le Borgne E, Dickinson N, and de Jong D for IRC International Water and Sanitation Centre. (2011) Documenting change: an introduction to process documentation.

Ross J, Karlage A, Etheridge J, Alade M, Fifield J, Goodwin C,  Semrau K, and Hirschhorn L. (2021) Adaptive learning guide: A pathway to stronger collaboration, learning, and adapting.

Schouten T, Mizyed B, Al-Zoubi R, Abu-Elseoud M, Abd-Alhadi FT. (2007) The inside story: Process documentation experiences from EMPOWERS.

Nyangara N and Callaghan-Koru J. (2015) An approach for documenting program processes of public health interventions.


References

Bennett C, Jones R. (2020) When this is over, will we know how we got here? Lessons from process documentation from an implementation research project.

da Silva Wells C, Le Borgne E, Dickinson N, and de Jong D for IRC International Water and Sanitation Centre. (2011) Documenting change: an introduction to process documentation.

Dawson P, Pradhan YV, Houston R, et al. (2008) From research to national expansion: 20 years’ experience of community-based management of childhood pneumonia in Nepal. Bulletin of the WHO 86(5):339-343.

Hirschhorn L, MOMENTUM Project. (2020) Responding to COVID-19: Evidence from previous disease outbreaks and what it means for MNCH/FP/RH programs today.

MOMENTUM Project. (2020) Effects of COVID-19 on essential MNCHN/FP/RH care and the strategies and adaptations emerging in response: Rapid evidence summary.

Nyangara N and Callaghan-Koru J. (2015) An approach for documenting program processes of public health interventions.

Peek N, Starr L for USAID Learning Lab. (2019) Theory of change review as an adaptive management tool.

Ross J, Karlage A, Etheridge J, et al. (2021) Adaptive learning guide: A pathway to stronger collaboration, learning, and adapting.