CLINICAL GUIDELINES
DEVELOPMENT
Dr. Chisale Mhango
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
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.
POLICY GUIDELINES
1. Malawi National Health Policy
2. All Malawi Programme Policies
1. Must be aligned to the National Health Policy
e.g. National Reproductive Health Policy
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
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
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.
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.
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.
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.
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
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.
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.
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.
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
Process of Developing the Clinical
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.
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.
How is the Clinical Guidelines are
structured
Part I:
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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
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)
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.
TO ENSURE BEING UP TO DATE
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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
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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
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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
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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 Delivery
Guidelines, 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.