The guidelines implementation process is a complex one that involves individuals at many levels of the healthcare system. There is no one approach that will work in all countries; instead, the process of guidelines development and implementation must be tailored to suit each country in which it is undertaken. For example, in some countries where the healthcare system is decentralized, the development process may take place at two levels, with policy guidelines set at the national level and service delivery guidelines developed at the state or district level. This paper will describe a guidelines development process that reflects the scenario common in many countries, but this should not be construed to be the only pattern by which guidelines come about.
Developing Guidelines
In a logical framework, maternal and neonatal health policy would be set first and national service delivery guidelines would be developed based on that policy. In reality, service delivery guidelines are often developed first and then used to influence the national reproductive health policy. In countries with limited political commitment to safe motherhood, it may be effective to begin policy development by first building consensus among leaders in the healthcare community on the need to standardize the way services are provided and change the way clinical training is conducted. Although the following steps may not proceed in the sequence in which they are presented, nor even at the same level of the healthcare system, they are a set of activities that are essential for implementation of guidelines at healthcare provider level.
Identify Stakeholders and Gain Consensus on Need for Change
Implementing standards of care usually necessitates changes in national healthcare policy, for example, giving nurse-midwives prescriptive authority, placing critical maternal and neonatal drugs on the essential drug list and deciding whether the community should pay for maternal health services. To start this process, however, there must be political will to change. Political will requires that policymakers understand the issues, be motivated to change and have the resources and skills to effect and enforce change.
| Several Zambian Health Agencies Take Preliminary Steps Toward Developing Guidelines
The process of developing maternal health clinical guidelines in Zambia began with sensitizing key stakeholders. To start, the MNH Program was invited to update the skills of a group of midwifery faculty and clinicians, including obstetricians/gynecologists, who were identified to strengthen the midwifery curriculum. This team worked with the General Nursing Council (GNC) and the Department of Obstetrics and Gynecology at the University Teaching Hospital (UTH) to develop and implement a prototypical set of MNH protocols. Using these protocols, two practice sites in Lusaka, at UTH and a district clinic providing maternal health services, were strengthened, and the midwifery curriculum strengthening team (15 faculty and clinicians) was updated in key MNH skills. The team has now reviewed and suggested revisions to the registered midwifery curriculum based on the protocols and the expanded scope of practice defined in the Nurses and Midwives Act, which has been passed and will be put into action as soon as the commencement order is given.
Reproductive health staff at the Zambian Central Board of Health (CBOH), UTH's Department of Obstetrics and Gynecology, and the GNC have been sensitized to the need for developing clinical guidelines. Copies of Managing Complications in Pregnancy and Childbirth and the draft Essential Maternal Health Care Clinical Guidelines and Protocols for Uganda have been distributed to key decision-makers. As a result, CBOH has included the development of maternal health clinical guidelines in its action plan for 2001, and a preliminary timeline has been developed. Meanwhile, MNH staff continue to sensitize senior staff at CBOH. The MNH team in Zambia is working on finalizing the timeline, gaining agreement on the process and developing a guidelines technical working group. |
Key to the policy process is the identification of stakeholders— nationally and locally. Stakeholders for safe motherhood are found in ministries of health, other relevant ministries (e.g., women's affairs, finance, education), health regulatory bodies (e.g., nursing councils), universities, NGOs, private voluntary organizations (PVOs), professional associations, women's groups, and donor and technical assistance agencies, among others. Representative stakeholders at regional, district and community levels are also identified and the issues they see as potential solutions or obstacles to the problems of safe motherhood are mapped out. This information is used to guide the development of strategies for policy change. In addition to being a multisectoral group, stakeholders are also multidisciplinary: policymakers, healthcare providers, supervisors, managers, educators, private sector officials, community leaders and clients.
| Nepal Stakeholders Identify Challenges to Implementation of Safe Motherhood Standards
During the process of planning for implementation of Nepal's national guidelines, called Reproductive Health Clinical Protocols, stakeholders identified the following challenges that would have to be met if the protocols were to be implemented effectively:
- Policy challenges
- pattern of frequent staff transfer
- low staff morale
- inconsistent posting of staff to rural areas
- inadequate supervision and support for providers
- inadequate logistics systems for supplies
- Donor challenges
- need for improved coordination among donors
- much collaboration driven by individual personalities
- central office agendas of donor agencies that conflict with government goals
- Training challenges
- healthcare providers with poor basic skills
- training sites with low caseloads
- extensive time required for training
- Low demand for services
- lack of access to rural communities
- differing perceptions among community members about pregnancy, childbirth and illness
- caste, class and gender differences between healthcare providers and community members
As a result of this identification of challenges by the stakeholders, it was possible to develop strategies for overcoming obstacles before implementation even took place. |
Once stakeholders are identified, information and advocacy efforts are made to ensure that these stakeholders are "on board." If they are not motivated to make changes and do not feel a sense of ownership in the process, it is unlikely that significant change will occur. The means of generating this sense of ownership will take different forms in different countries—educational seminars, national symposia, technical update workshops, rallies, individual meetings, etc. One common need, regardless of the methodology, is for the stakeholders to have accurate, up-to-date, global information about the challenges of maternal and neonatal health and their solutions. They also must have evidence-based information on best practices in order to convince decision-makers of the need to change. These kinds of information are readily available from organizations such as WHO, JHPIEGO/MNH, etc. (see
Table 1).
Form a National Advisory Group
Ensuring that healthcare providers deliver maternal and neonatal healthcare according to the standards set out in service delivery guidelines is a challenge. It will take several years to accomplish and will require enthusiastic and continual support from numerous non-health sectors as well as the ministry of health. Countries that have tried to implement guidelines entirely through the efforts of the ministry of health have generally had disappointing results. The greatest probability of success is tied to the establishment of a dynamic, multidisciplinary, multisectoral safe motherhood committee or advisory group. The form that this group takes, the authority that it has and its placement within or outside government vary from one country to another, but every country that has claimed success in driving down high levels of maternal and neonatal mortality has had some type of active, highly visible and highly placed safe motherhood committee.
This committee, or a sub-group of it, can spearhead the preparation of the policy documents and service delivery guidelines. If it has sufficient authority, it can co-opt appropriate leaders to contribute to the standards and guidelines, organize guidelines field-testing and revision, advocate for their ultimate approval and adoption, and encourage their implementation at regional and district levels.
This kind of group is extremely useful, if not essential, to the guidelines development and implementation process. It should be formed as soon as possible after the stakeholders have been identified and they have reached consensus on the need for change. At that time, enthusiasm is high and stakeholders are most willing to commit to this effort. Members are usually well known and highly respected persons in fields related to safe motherhood. They may be leaders of government, universities, healthcare institutions and local NGOs; the group may also include respected private individuals, among others. Their collective voice carries the necessary weight to move programs past the inevitable obstacles that arise.
Even after standards are achieved, it will be necessary to review practices as new information becomes available. The national advisory group should therefore be considered a permanent or semi-permanent advisory group. In some cases, the advisory group for guidelines implementation may be a subcommittee of the national safe motherhood committee.
Develop/Revise Draft National Policy Guidelines
Policies embodying national standards address the overarching maternal and neonatal health priorities and capacities of a country. National standards based on best practices must be accepted and introduced within a realistic framework of the country's needs, available resources and program priorities. Revision of national policy guidelines entails adapting best practices to suit those specific needs, resources and capacities. There is rarely just one best practice, but often a multitude of them, and it is up to the stakeholders to identify which ones best meet their needs and priorities.
National policy statements need to outline and support effective logistic, healthcare delivery, training and supervisory systems and monetary allocations to implement the service delivery guidelines and reach nationally recognized standards of care. They may be developed or, more often, revised by a subgroup of the national advisory group or safe motherhood committee, or by another group of stakeholders.
As decentralization of health services and fee-for-service schemes become more prevalent, and as more community organizations participate in the management of health facilities, the group of stakeholders who draft or revise policy documents nowadays usually includes both representatives of healthcare providers and the communities to be served. This representation ensures that the policies developed reflect the healthcare priorities of both groups. Standards of care thus developed provide the community with the guidance needed to evaluate and promote these services.
To draft or revise national standards policy, stakeholders normally use internationally accepted resource materials and determine how these can best be applied in the context of their own country. This process sets an achievable level of quality within the possibilities and constraints of the country's situation (taking into consideration its needs, resources and priorities), while fostering a sense of ownership for the resulting documents by stakeholders at all levels.
Policy documents should highlight all aspects of maternal and neonatal health services (antenatal care, normal childbirth, treatment of emergencies, postpartum care, neonatal care, nutrition) and their linkages to other reproductive health services (e.g., postabortion care, family planning). They should include information on case management and set standards for the delivery and supervision of maternal and neonatal health services, community involvement, relationship with other reproductive health services, and required equipment and supplies. Policy documents, and the standards they set, become practical statements when they are used to develop or modify service delivery guidelines, supervision guides, training materials, drug and supply lists, and other tools that improve provider performance.
| Diverse Stakeholders in Guinea Revise, Validate Policy Guidelines After Situational Analysis
In April 2000, the Ministry of Health (MOH)/Guinea requested that USAID provide technical assistance to revise the national safe motherhood document. USAID transmitted this request to the MNH Program, and in July 2000 the national safe motherhood revision team conducted a situational analysis of maternal health in Guinea. This analysis was based on findings from site visits by the team, joined by other healthcare providers experienced in assessment, to service delivery points in seven rural prefectures and four urban communes in the country's four geographic regions.
Immediately following the situational analysis, a workshop which used a participatory approach was held to redefine the strategic focus, objectives and activities of the safe motherhood program. The 30 workshop participants were a diverse group of stakeholders, including regional and prefectural health inspectors, healthcare providers from all levels of Guinea's decentralized healthcare system and representatives from local and international NGOs. The information from the revision workshop was then used to complete a draft revision of the safe motherhood program document (policy guidelines). In November 2000, the national revision team held a validation workshop for the document with the collaboration of the MNH Program to determine the final form of the document and develop a national safe motherhood action plan. |
Develop/Revise Draft National Service Delivery Guidelines
The development of service delivery guidelines based on accepted, or soon-to-be-accepted, national standards can be a complicated process. Their successful development depends upon the national advisory body, or another designated group, which drives the revisions and adapts guidelines to their country's specific needs, resources and priorities. The drafting group, which comprises writers, reviewers and sometimes even a legal advisor, works from the international resource materials to generate unique guidelines appropriate to the country. Because of the technical nature of the guidelines, if the drafting group does not include experienced clinicians, these individuals are made available to it on a consultative basis.
Development of service delivery guidelines demands certain information about the healthcare services situation in the country. When this information is not readily available, a needs assessment is often performed to collect the missing pieces. A full-blown and expensive needs assessment is usually not necessary, but a carefully focused, small-scale needs assessment designed to fill in the gaps and find answers to critical questions can be extremely useful.
The process of guidelines development also will include larger group discussions for feedback, reality testing, approval and endorsement of their adoption. This larger group includes members of health professions, service organizations, donors, professional associations, educational institutions, community representatives and clients.
National service delivery guidelines translate international standards into appropriate, practical instructions for skilled providers. They furnish details about how and by whom services are to be managed and delivered. They generally include protocols for the performance of specific maternal and neonatal healthcare tasks, drug, equipment and supply lists, and supporting measures such as infection prevention practices. Guidelines permit healthcare delivery, training, supervision, logistical support and management practices to be of consistently high quality at all levels of the healthcare system. They provide the means to standardize healthcare delivery practices needed to support quality clinical healthcare. Guidelines can only be implemented effectively, however, when policy supports them, necessary resources and infrastructure are present, effective healthcare delivery support systems are in place and both the community and providers feel ownership of them.
| Ugandan Service Delivery Guidelines to Be Used for Training and Service Delivery
The process for developing the essential maternal and neonatal healthcare (service delivery) guidelines in Uganda involved a series of participatory activities with a group of over 30 leading Ugandan healthcare providers and decision-makers. These activities included maternal and neonatal health technical updates for key stakeholders, improved access to information on effective practices, drafting and review of individual sections of the proposed guidelines document, and meeting to present and critique the final draft versions that were produced. The result is a document, Essential Maternal & Neonatal Care Clinical Guidelines for Uganda, which focuses on improving maternal and neonatal survival through improvements in antenatal care, labor and delivery, postnatal care, management of abortion complications, postpartum contraception and infection prevention.
These service delivery guidelines provide basic maternal and neonatal healthcare standards for assisting providers in the decision-making process for services, and will be critical resource documents for training, quality improvement, information, education and communication initiatives, and healthcare delivery programs. The participatory manner in which the guidelines were developed ensured not only that they reflect and respond to real needs and concerns, but also that they foster broad acceptance and implementation when used in maternal and neonatal health programs.
The Essential Maternal & Neonatal Care Clinical Guidelines for Uganda, which adapted essential content from the WHO resource document Managing Complications in Pregnancy and Childbirth, has been instrumental in shaping key policy and training documents such as the Minimum Package of Reproductive Health Services for Uganda, the Ob/Gyn Medical Internship package, and the preservice component of the midwifery curriculum on essential maternal and neonatal healthcare. The document has also been a model for similar efforts in other countries in the East and Southern Africa region that have expressed interest in adapting it for their own
needs |
Validate Draft Documents Through Review by Key Stakeholders External to the Advisory Group
To achieve true national ownership, policy guidelines require a thorough review by the stakeholders and then by a larger group of interested parties external to the advisory group. Service delivery guidelines, because of their technical nature, require a more extensive review process. They are first field-tested by groups of providers at various levels and types of facilities and by different cadres of health services personnel. Often the draft guidelines have to be translated into supervisory checklists or training materials for field-testing. Feedback is obtained from the test sites and analyzed by the drafting committee. This feedback includes not only the reaction of the healthcare delivery system to the guidelines, but also the response of clients and the community. It leads to revision of the guidelines document in preparation for its final, official endorsement.
| Collaboration Among Agencies Ensures Successful Field-Testing and Validation of Guidelines in Nepal
Through close collaboration of the government with a number of bilateral and international organizations, CAs and NGOs, service delivery guidelines for reproductive health were developed in Nepal. Agencies cooperating with the His Majesty's Government included USAID, UNFPA, the UK Department for International Development (DFID), the German Technical/Development Assistance Organization (GTZ) and WHO. These guidelines were then field-tested through the collaboration of two more agencies: Redd Barna and the United Missions to Nepal. Following the field-test, they underwent extensive revision and were shaped into seven volumes called Reproductive Health Clinical Protocols. The Protocols were designed to give all cadres of healthcare providers specific guidance on how to treat common occurrences and make clinical decisions.
Despite many challenges, the experience in Nepal demonstrated that collaboration among many organizations can be successful in developing, testing and disseminating guidelines that embody national standards of care. |
Endorse Officially the Policy Document and Service Delivery Guidelines
Once reviewed and revised as needed, policy documents generally require full government approval. The pathways, individuals and government levels required for this approval vary widely from one country to another, but the need for official approval remains invariable if the standards are to be applied effectively and consistently to national healthcare provision.
