CLINICAL GUIDELINES DEVELOPMENT

1. CLINICAL GUIDELINES DEVELOPMENT Dr. Chisale Mhango

2. MALAWI SCENARIO • MOH has a number of guidelines in several national programmes • RHU has an integrated Guidelines, called “Malawi National Reproductive Health Service Delivery Guidelines” • These are elaborated by the • National Reproductive Health Standards • Clinical Protocols

3. MALAWI NATIONAL GUIDELINES • In Malawi, the word “guidelines” is a generic term for various documents that describe how standards are achieved. • Two broad types of guidelines exist at national level: • policy guidelines, and • service delivery guidelines.

4. POLICY GUIDELINES • Malawi National Health Policy • All Malawi Programme Policies • Must be aligned to the National Health Policy e.g. National Reproductive Health Policy

5. POLICY GUIDELINES The Malawi National Health Policy is recently revised and is aligned to the • WHO Policy Guidelines • African Union Health Strategy, and • Southern African Development Community NB communities that Malawi belongs

6. Policy Guidelines Policy Guidelines describe: • Which services are to be officially offered • Who may receive these services • Where these services will be delivered • How often certain services are to be delivered and • What minimal acceptable level of performance is to be offered

7. Policy Guidelines Policy guidelines do not contain the technical information needed to provide services; rather, they serve as a general outline for the provision of services.

8. 1. Malawi Reproductive Health Policy • This recently revised. • It addresses all components of reproductive health • How much each of these components are covered depends on the SWAp programme of work • Cancer is just being covered in the SWAp PoW now hence the need for revising the policy.

9. 2. Malawi Reproductive Health Policy • Recent changes in the delegation of the delivery of DMPA to HSAs, necessitated the revision of the policy. • It had to meet the values of the recently developed Health Policy. • Guiding principles are those identified in the Health Policy. • Cancer is just being covered in the SWAp PoW now hence the need for revising the policy.

10. 1. Service Delivery Guidelines Service Delivery Guidelines serve as • A technical tool for achieving standards. • They highlight essential information on delivery of services. • They are a source of specific, up-to-date information about the reproductive health services offered in a country.

11. 2. Service Delivery Guidelines • They explain how healthcare providers should relate to clients and patients who seek reproductive health services. • They serve as a basis for RH learning, resource material and curriculum development. • They are logically are derived from the policy guidelines. • The are supplemented by the TRAINING MANUALS

12. Standards • WHO defines standards as an agreed-upon level of performance that specifies what action should be taken. • They serve as the benchmark upon which to make judgements. • They must be achievable, desirable and measurable and most importantly, standards of care should be evidence-based with focus on client/patient needs. • Logically, the standards are derived from the service delivery guidelines.

13. PURPOSE OF MRHSDG The Malawi National Reproductive Health Service Delivery Guidelines provide the most current up-to-date knowledge and direction on the various components of reproductive health, as at the time of writing.

14. 1. Objectives of Clinical Guidelines • To assist service providers at all levels of care to deliver high-quality comprehensive and up to date RH services based on sound and acceptable principles of practice. They form a solid foundation from which service providers at all health facilities in both the public and private sectors, as well as non-governmental organisations, can provide comprehensive,and standardised reproductive health care. The MoH obliges all managers, policymakers and training institutions to use of these guidelines.

15. 2. Objectives of Clinical Guidelines • In the health sector, there are many WHO and other international institutions guidelines. • As occurs in most countries, Malawi takes advantage of the international expertise that developed these guidelines, and adapts them. • On being adapted, the ownership of those guidelines changes: the become national guidelines. • There is no obligation to use international guidelines, but all are obliged to abide by national guidelines

16. Process of Developing theClinical Service Delivery Guidelines • Multi-sectoral: the current MNRHSG acknowledges 38 technical persons from 23 organisations who participated in the development of the 2nd edition of these guidelines in 2007. • These persons used their field experiences as well as recent scientific literature and current research findings to formulate a document that is consistent with good clinical conduct through several workshops.

17. FINALISATION OF THE CLINICAL GUIDELINES The draft Guidelines were then circulated to various stakeholders to review each and every chapter thoroughly, ensuring that each component is consistent, technically sound and evidence-based.

18. How is the Clinical Guidelines are structured Part I:   • Quality of care • Counselling • Client assessment • Infection prevention • Family planning • Post abortion care • Adolescent reproductive healthcare • Maternal and neonatal health • Sexually Transmitted Infections (STI’s) • Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV and AIDS) • Prevention of Mother to Child Transmission (PMTCT) of HIV • Reproductive health for special groups • Prevention and early detection of cancers of the reproductive system • Infertility • Gender Based Violence • Harmful practices • Logistics Management System Part II:   • WHO Medical Eligibility Criteria for Contraceptive use • Who Can Provide FP services • Standard Equipment and Supplies for RH services

19. Limitations of the Malawi National RH Service Delivery Guidelines? • These guidelines are comprehensive in scope, but they do not provide detailed procedures in service provision. • They only highlight the essential information that guide the delivering of RH services. • If the reader/user needs to know the detailed steps in the various chapters, s/he is to consult clinical protocols, agreed upon standards and/or procedure manuals. • What is possible is dictated national available resources (e.g. VIA instead of Pap smear)

20. ETATMBA OBSTETRIC PROTOCOLS • The arrangement of the Service Delivery Guidelines in Malawi is different from those of Tanzania. • The Malawi RH Service Delivery Guidelines are generic for all health workers • Hence while ETATMBA has revised the Tanzania Service Delivery Guidelines for the NPCs, in Malawi ETATMBA has upgraded the OBSTETRIC PROTOCOLS, as these will be what is required to meet the needs of Clinical Officers – the target group for the ETAMBA intervention.

21. TO ENSURE BEING UP TO DATE • DFID/USAID/UNICEF/UNFPA. Malawi Demographic and Health Survey, December 2005 • FHI/USAID. September 1997. Reproductive Health of Youth Adults • Hatcher R A, et al. July 1997. Essentials of Contraceptive Technology • http://www.aidsinfo.nih.gov • http://www.niaid.nih.gov • http://www.oncolink.org • JHPIEGO/USAID/ ENGENDERHEALTH. April 2003. Post-abortion Care Course Notebook for Trainers, • JHPIGO.1999.Reproline-Reproductive Health • Ministry of Health. /NAC, Guidelines for the Use of ARV’s in Malawi, First Edition October 2003 • Ministry of Health. 2003. Prevention of Mother to Child Transmission of HIV, Guidelines for Implementer) • Ministry of Health. Guidelines for Management of STI VO. 03 MAY 2004 • Ministry of Health. July 2005. Emergency Obstetric Care Services in Malawi (Report of a Nationwide Assessment) • Ministry of Health. March 2004. Neonatal Care Protocols • Ministry of Health. Obstetric Life Saving Skills Manual (Updated) July 2006 • Ministry of Health. Obstetric Life Saving Skills Manual Original, March 2000 • Ministry of Health. PMTCT Guidelines for Implementers, 2003 • Ministry of Health. Rape and Sexual Assault Service Delivery Guidelines • Ministry of Health. Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity, October 2005 • Ministry of Health.2003. Prevention of Mother to Child Transmission of HIV, Handbook for Health workers • Ministry of Health/JHPIEGO. Cervical Cancer Service Delivery Guidelines, April 2005 • Ministry of Health/JHPIEGO. Infection Prevention Standards, April 2006 • Ministry of Health/JHPIEGO. Reproductive Health Service DeliveryGuidelines, October,2001 • Ministry of Health/JHPIEGO. Reproductive Health Standards, November 2006 • Ministry of Health/JHPIEGO. Reproductive Health Strategy, June 2006 • Ministry of Health/JHPIEGO. Reproductive Health/Family Planning Learning Package for Preservice Education, November 2002 • Ministry of Health/NAC, Management of Sexually Transmitted Infections Using Syndromic Management Approach, Guidelines for Service Delivery, Second Edition Vo. 03 May 2004 • Online.http://www.reproline.jhu.edu • Tietjen L, Cronin W, March 1992. McIntosh N, Infection Prevention for • Family Planning Service Programs • WHO/UNFPA/UNICEF/WORLD BANK. 2003. Managing Newborn Problems • Winkler J, Oliveras E, McIntosh N, 1994. Postabotion Care Reference Manual for Improving Quality of Care • World Health Organization (WHO). 2004. World Health Organization Medical Eligibility Criteria for Contraceptive Use • World Health Organization(WHO). 2002. Managing Complication in Pregnancy and Child Birth (Addendum for use in the African Region,) 2002 • World Health Organization(WHO). 2002. Managing Complications in Pregnancy and Child Birth (A guide for midwives and child health) • Ministry of Health of Kenya. Family Planning Guidelines for Service Providers March 2005 • Hatcher, RH, Rinehart, W, Blackburn, R, Geller, J.S., and Shelton, J.D. The Essentials of contraceptive Technology. Baltimore, Johns Hopkins University School of Public Health, Population Information Program, 1997.