Guidelines

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Guidelines
MAQ Exchange
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Objectives

• Define components of guidelines
• Explore impact of guidelines on maximizing access
  and quality
• Describe best and better practices in the
  guidelines process

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Introduction

• Guidelines are one of the key tools for promoting
  MAQ and may include several components
• Service policies
• Service standards
• Service protocols (procedures)
• Service plans

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Introduction

• Guidelines have great potential for impact on
  access and quality because they
• Provide a framework around which high quality
  services can be built or reinforced
• Reduce medical and access barriers
• Standardize provider practices

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Introduction

• Guidelines also have great potential for impact
  on access and quality because they
• Guide supervisory and management systems
• Guide the content for training and preservice
  education programs
• Establish a focus and standards for training and
  criteria for evaluation

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Introduction
Expansion of services
Access to services

• Number of users (increase)

Guidelines
Specification of required equipment and supplies
Number and types of providers (increase)
Standardization of training
Improvements in quality
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Guidelines Road
Steps in the Guidelines Process
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Guidelines Road
Step 1 Establish need for Guidelines
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The Essential First Step Establishing Need
1

• Review data
• Collect existing documentation
• Conduct needs assessment

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Guidelines Road
Step 2 Assure host country commitment
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Ensure Broad Scope andCommitment
2

• Solicit opinion of all stakeholders
• Solicit policy level support through strategic
  and frequent meetings with senior officials
• Prepare a plan and obtain commitment and approval
  to participate in plan
• Form a broad-based committee to steer process

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Ensure Broad Scope andCommitment
2

• Expert Committee in Turkeys National Guidelines
  Development
• Representatives of
• Ministry of Health
• University
• Service providers, trainers, and their
  professional associations
• Local NGOs, FP associations
• UNFPA and USAID cooperating agencies

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Guidelines Road
Step 3 Develop outline and content
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Develop Outline and Content
3

• Get input from all levels of the health service
  system pyramid

• Identify practices that are positive
• Conduct broad discourse on proposed guidelines

• Utilize national and international resources

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Develop outline and content
3
Central Level
Regional Level
District Level
In Niger, each level of the health system was
assessed in order to develop guidelines that were
appropriate.
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Outline and ContentUtilizing Resources
3

• Reference documents and resources guide the
  formulation of up-to-date guidelines

• WHO Eligibility Criteria
• USAID Recommendations for Updating Selected
  Practices in Contraceptive Use
• JHPIEGO Infection Prevention reference manual
• CPI guidance documents

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Development of National RH/FP service policies
and standards
3
Developing Guidelines for Ghana
National dissemination of policies and standards
Zonal dissemination of policies and standards
PAC Training of Midwives
Develop field test strategy for RH protocols
Train service providers in use of protocols
Development of RH protocols
Developed Safe Motherhood protocols
1994
1995
1996
1997
1998
1993
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Guidelines Road
Step 4 Pretest, complete and obtain approvals
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Testing and Revising
4

• Field testing done by a variety of providers
• Review for technical accuracy, user-friendliness,
  internal consistency
• Revisions should reflect client perspectives
• Review and revise with sanctioning authorities

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Guidelines Road
Step 5 Plan dissemination
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Get Ready For Dissemination!
5

• Host country plans strategy and ensures adequate
  funding
• Formulate clear and flexible workplan
• Plan to use a wide variety of formats
• Go beyond distribution to ensure application in
  plan

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Guidelines Road
Step 6 Disseminate and promote
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Dissemination Strategies for Success
6

• Involve and reach all organizations concerned
• Plan series of workshops for different groups at
  different levels of service
• Issue an official letter validating the
  guidelines and use other opportunities to
  broadcast them officially
• Promote using creative mechanisms

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Creative Dissemination and Promotion Strategies
6

• Radio dramas
• Dissemination workshops
• Flyers
• Internet
• Hotlines
• Audio cassettes
• Posters and logos
• Modeling by respected colleagues

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Guidelines Road
Step 7 Apply
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Apply Hit All the Targets
7

• Service delivery points
• Training programs
• Education programs
• Program planning
• Community linkages Source Population
  Reports, Series J, Number 47, 1998.

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Application in Service Delivery Kenya Example
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• vs.
• Pregnancy safely ruled out by checklist in 90 of
  women typically sent home
• Of those pregnancies ruled out by checklist only
  lt1/2 had a positive pregnancy by test

Pregnancy Checklist
DipstickÒ Pregnancy Test
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Guidelines Road
Step 8 Encourage Adherence
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8
Ownership Encourages Adherence
Use positive, team- based approaches that make
providers partners in promoting guidelines use
and solving problems in their application!
Source Population Reports, Series J, Number 47,
1998.
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Build Adherence Into The System
8

• Identify focus of responsibility for adherence
  and authority for ensuring it
• Ensure orientation and training around guidelines
• Look beyond the guidelines for causes of lack of
  adherence

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Ecuador Sustainability Study
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Explore Reasons for Non-Adherence

• Before CEMOPLAF policy on IUDs required 4
  revisits
• Study on impact of reducing mandatory IUD
  follow-up visits to 1
• Results actual revisits reduced 36 while only
  detecting 7 less serious medical complications
• Savings 23,000 for clients, 10,000 for
  CEMOPLAF, 1800 provider hours annually

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Provide The Tools for Adherence

• Send periodic content pieces reinforcing
  guidelines--especially problem-solving tips and
  solutions found by practicing colleagues
• Develop/use job aids and coaching

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8
It is also important to tell providers what not
to do!
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8
Monitor Adherence
Methods to monitor adherence

• Self assessment (with checklist)
• Supervision and training
• Follow-up
• Peer review
• Medical monitoring
• Record review
• Client surveys
• Action research

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Guidelines Road
Step 9 Update
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UpdateKeep Up With The Times

• Plan for periodic review early in process
• Provide content and program updates to steering
  committee
• Plan for host country self-reliance for
  guidelines revisions and updates
• Establish mechanisms for providing technical
  professionals in the field with up-to-date
  scientific information

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Planning for Update in Tanzania
Revise guidelines to include other reproductive
health content and reflect health sector/package
reforms
First version of guidelines available
Need for guidelines established
Guidelines revised
1990
91
92
93
94
95
96
97
98
99
2000 gt
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Guidelines Road
Step 10 Evaluate
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Evaluation Tips
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• Evaluate the integration of guidelines in daily
  service provision practices

• Evaluate impact on access to and quality of care,
  and accordingly take initiatives to strengthen
  these

• Integrate indicators into existing data
  collection systems

• Apply results of evaluation to new initiatives to
  strengthen quality and access

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Impact of Guidelineson Improved Service Access
Quality
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Impact of Guidelines
Indicators of impact on service delivery
performance
1. Expanded services menu and method mix and
expanded service hours 2. Reduced policy and
practice barriers to contraceptive access 3.
Improved service delivery environment
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Impact of Guidelines
Indicator 1 Expanded services menu and method
mix and expanded service hours

• Increase in sites in 15 target provinces offering
  services (54 to 81)

Burkina Faso
sites offering services

• Injectables, formerly available only from
  physicians, now dispensed by trained nurses
  as well.

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Impact of Guidelines
Indicator 2 Reduced policy and practice
barriers to contraceptive access
Bolivia, Guatemala, Peru, Brazil

• Adherence to WHO recommendations

• Elimination of unnecessary laboratory tests
  before starting hormonal methods

Cameroon, Senegal

• Changes in eligibility criteria
• Example 130 increase in number of injectable
  users and 99 increase in number of women
  choosing sterilization

Ghana
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Impact of Guidelines
Indicator 3 Improved service delivery
environment

• Improved provider-client communication and
  counseling relationships.
• New service management approaches
  recommended--including reconfiguration of
  physical space in some clinics--offering clients
  more privacy and confidentiality.

Uganda
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