Implementation guide for the medical eligibility criteria and selected practice recommendations for contraceptive use guidelines: a guide for integration of the World Health Organization

Publication date: 2018

00 IMPLEMENTATION GUIDE FOR THE MEDICAL ELIGIBILITY CRITERIA FOR CONTRACEPTIVE USE AND SELECTED PRACTICE RECOMMENDATIONS FOR CONTRACEPTIVE USE GUIDELINES A guide for integration of the World Health Organization (WHO) Medical eligibility criteria for contraceptive use (MEC) and Selected practice recommendations for contraceptive use (SPR) into national family planning guidelines IMPLEMENTATION GUIDE FOR THE MEDICAL ELIGIBILITY CRITERIA FOR CONTRACEPTIVE USE AND SELECTED PRACTICE RECOMMENDATIONS FOR CONTRACEPTIVE USE GUIDELINES Implementation guide for the medical eligibility criteria and selected practice recommendations for contraceptive use guidelines ISBN 978-92-4-151357-9 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY- NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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Printed in Switzerland I II CONTENTS 2 INTEGRATING WHO FAMILY PLANNING GUIDANCE INTO NATIONAL FAMILY PLANNING GUIDELINES: RECOMMENDED PROCESS 5 2.1 Exploration stage: mapping the current country family planning guidelines and the status of their use 6 Goals of the exploration stage 6 Activities of the exploration stage 6 2.2 Installation stage: launching practical preparations for introduction of revised national family planning guidelines 8 Goals of the installation stage 8 Activities of the installation stage 8 2.3 Initial implementation stage: roll-out of revised national family planning guidelines 10 Goals of the initial implementation stage 11 Activities of the initial implementation stage 10 2.4 Full implementation stage: full implementation of MEC/SPR guidance through national family planning guidelines 12 Goals of the full implementation stage 12 Activities of the full implementation stage 12 2.5 Sustainability of the MEC/SPR guidance in national family planning guidelines 14 1 INTRODUCTION TO THE IMPLEMENTATION GUIDE 1 1.1 Introduction to implementation science 2 1.2 Target audience: who should use this guide? 3 1.3 Purpose of the implementation guide 3 1.4 Elements of the implementation guide 3 1.5 Methods for developing the implementation guide 3 1.6 Adaptation of the MEC/SPR guidance to the national context 4 3 CONCLUSION 16 4. RESOURCES & SUPPORT IN THE IMPLEMENTATION OF MEC/SPR GUIDANCE 17 5 REFERENCES 17 This document is the result of collaboration between the World Health Organization (WHO) Department of Reproductive Health and Research and international experts in family planning. Funding and other support for this collaboration was provided the Bill & Melinda Gates Foundation through the Family Planning Umbrella Grant. This support is gratefully acknowledged. Sarita Sonalkar, consultant, was the principal technical writer. The development of this implementation guide was led by Sarita Sonalkar and Mary Lyn Gaffield of WHO. Anne Warren and Jane Werunga-Ndanareh provided administrative support to the document team throughout the process. Jane Patten of Green Ink provided editorial assistance. Layout and design was by Lushomo Communications, South Africa. The framework for this document was developed by a working group which met on 13–14 April 2016 at WHO headquarters in Geneva, Switzerland. This working group comprised 10 international family planning experts from Bangladesh, Ghana, Iran, Madagascar, Thailand, the United Kingdom of Great Britain and Northern Ireland, and the United States of America, as well as seven WHO staff. These working group members included Richard Adanu, Ferdousi Begum, Kathryn Curtis, Mohammad Eslami, Mary Lyn Gaffield, Anna Glasier, Rita Kabra, James Kiarie, Caron Kim, Titlope Oduyebo, Herbert Peterson, Suzanne Reier, Yvette Ribaira, Vinit Sharma, Sarita Sonalkar and Kate Whitehouse. ACKNOWLEDGMENTS Their input was incorporated into the draft, which then served as the basis for deliberations during an Implementing Best Practices (IBP) stakeholder consultation on 11 August 2016 in Washington, DC. Participants at this consultation included Anna Altshuler, Rati Bishnoi, Christine Bixiones, Kate Cho, Megan Christofield, Emma Clark, Margaret D’Adamo, Beth Frederick, Mary Lyn Gaffield, Merce Gasco, Kamlesh Giri, Joanne Gleason, Mark Hathaway, Lisa Hilmi, Roy Jacobstein, Victoria Jennings, Candace Lew, Ronnie Lovich, Ados May, Titilope Oduyebo, May Post, Michelle Prosser, Jessica Reinholz, Sharon Rudy, Abdulmumin Saad, Ruwaida Salem, Meg Schmitt, Wayne Shields, Sarita Sonalkar, Esther Tahrir, Lucy Wilson and Teshome Woldemedhin. Inputs from the IBP consultation were incorporated into the next draft, which was reviewed during a teleconference on 16 November 2016 by Anna Altshuler, Kathryn Curtis, Mary Lyn Gaffield, Yvette Ribaira, Vinit Sharma and Sarita Sonalkar. A final meeting of the working group was held in Geneva, 2–3 March 2017, to finalize the content of the document. Working group members in attendance at this meeting, some of whom were new to the group, included Richard Adanu, Anna Altshuler, Ferdousi Begum, Kathryn Curtis, Mohammad Eslami, Mary Lyn Gaffield, Rita Kabra, Heidi Quinn, Yvetta Ribaira, Joumana Haidar, Vinit Sharma, Sarita Sonalkar, Petrus Steyn and Esther Tahrir. We would like to express our deep appreciation to all who contributed their time and expertise towards the consensus-building process. 01 Offering the most evidence-based and up-to-date family planning care is a primary element of a sustainable family planning programme (1, 2). The World Health Organization (WHO) publishes two evidence-based guidelines on family planning service provision: the Medical eligibility criteria for contraceptive use (MEC), which provides guidance on the safety of various contraceptive methods for use in the context of specific health conditions and characteristics (3), and the Selected practice recommendations for contraceptive use (SPR), which provides guidance for how to use contraceptive methods safely and effectively once they are deemed to be medically appropriate (4). These guidelines are designed to be used together. Facilitating the implementation of the MEC and SPR guidance at the country level is crucial for the provision of comprehensive, evidence- based family planning services. This Implementation guide for the WHO medical eligibility criteria and selected practice recommendations 1. INTRODUCTION ABOUT THE IMPLEMENTATION GUIDE for contraceptive use [hereafter referred to as the “implementation guide for the MEC and SPR”] is part of a global initiative to translate guidance into practice, through the principles of implementation science. Implementation of MEC/SPR guidance through a national programme is a complex, multidisciplinary process that requires engagement from multiple stakeholders. Furthermore, implementation can and should be pursued in a systematic and evidence-based manner. This document presents a structured process that will aid countries in their efforts to incorporate the latest MEC and SPR guidance, and their updates, into national family planning guidelines. When considering any policy change related to family planning, it is important to ensure support for the country’s human rights obligations and to serve all populations, including those in humanitarian settings. Additional resources relating to human rights considerations can be found on the WHO website (http://www.who.int/reproductivehealth/publications/ family_planning/human-rights-contraception/en/). “Facilitating the implementation of the MEC and SPR guidance at the country level is crucial for the provision of comprehensive, evidence-based family planning services.” 1 02 Implementation science is the study and use of methods to promote the adoption and integration of evidence-based policies, practices and interventions into routine health care and public health settings. There are four implementation stages: (i) exploration, (ii) installation, (iii) initial implementation 1.1 INTRODUCTION TO IMPLEMENTATION SCIENCE BOX 1: IMPLEMENTATION SCIENCE BASICS: IMPLEMENTATION FRAMEWORKS Implementation stages: In the implementation of a programme, there are multiple decisions, actions and revisions needed to change the structures and conditions necessary to successfully implement and sustain new programmes and innovations. The process of change includes four stages that can lead to sustainability of the programme. These stages are not linear, and do not necessarily have a strict beginning or end. The implementation stages include exploration, installation, initial implementation and full implementation (Box 2). Improvement cycles support the purposeful process of change. In this guide, we discuss the use of structured cycles to affect and sustain change, and to scale up evidence-based practices in family planning (Box 3). Implementation drivers are key components of capacity and infrastructure that influence a programme’s success. They are the core components needed to initiate and support change at a local and national level. A full and sustainable family planning programme involves drivers at the provider level (e.g. qualified providers who are providing technically competent, evidence-based care), organizational level (e.g. accessibility, organization and efficiency of care, appropriate facilities and national policies, and secure commodities supply chains), and leadership level (e.g. supportive and proactive policy-makers and programme managers). Implementation teams are organized and active groups support the implementation, sustainability and scale- up of changes by using the other described frameworks of implementation: stages, drivers and improvement cycles. Forming an implementation team does not require new staff; existing staff often can fill the roles required of participants on the implementation team. These teams should consist of at least 3–5 people who have adequate time to dedicate to implementation activites and who can be accountable on a daily basis for guiding the process of change. These teams lead efforts at each stage to: • ensure completion of activities • identify barriers at each level of the system • ensure the use of effective interventions • and ensure that effective implementation strategies and methods are identified and used to produce outcomes (Box 2). In this guide, we describe the structure of effective teams that are able to promote the incorporation of the MEC and SPR guidance at the country and local levels (see section 2.1). EXPLORATION INSTALLATION INITIAL IMPLEMENTATION FULL IMPLEMENTATION Source: The National Implementation Research Network’s Active Implementation Hub [website], 2017 (8) and (iv) full implementation; these are described in turn in section 2 of this guide and in Boxes 1 and 2. Sustainability planning, including activities that ensure financial sustainability and monitoring and evaluation, is an active component underpinning all four implementation stages. 1 03 1.2 TARGET AUDIENCE: WHO SHOULD USE THIS GUIDE? 1.4 ELEMENTS OF THE IMPLEMENTATION GUIDE Ministries of health, national programme managers, WHO country offices, other concerned UN agencies, nongovernmental organizations (NGOs) providing sexual and reproductive health services, and implementing This implementation guide for the MEC and SPR offers practical information on how to adapt and implement WHO recommendations on contraceptive service delivery into national programmes, protocols and service packages. The accompanying Implementation guide toolkit contains the following resources to aid in the process of implementing the MEC and SPR guidance. 1.3 PURPOSE OF THE IMPLEMENTATION GUIDE The MEC and SPR are part of the process for improving the quality of care in family planning. The purpose of this implementation guide for the MEC and SPR is to facilitate the integration of the MEC/SPR guidance into national family planning guidelines. It aims to accomplish this through the following mechanisms: partners can all use this guide as an aid to incorporate the recommendations of the MEC and SPR into family planning guidelines at the national and local levels. 1 2 3 Offering guiding principles by which ministries of health and other nodal departments or implementing partners can lead the process of adapting the MEC and SPR into national service- delivery guidelines Delineating mechanisms for the MEC and SPR guidance to be disseminated for use in front-line health-care settings Helping countries assess and monitor their own process of full implementation of WHO guidance A recommended process for integrating WHO MEC and SPR recommendations into national family planning guidelines Resources for additional support in the adaptation of WHO MEC and SPR guidance Resources for the four stages of implementation Examples of successful examples of MEC/ SPR guidance adaptation in countries. Template materials Guides and tools The Bill & Melinda Gates Foundation provided a grant to WHO’s Department of Reproductive Health and Research for the preparation of this implementation guide. An initial meeting of a core working group – comprising 10 international family planning experts from Bangladesh, 1.5 METHODS FOR DEVELOPING THE IMPLEMENTATION GUIDE Ghana, Iran, Madagascar, Thailand, the United Kingdom and the United States, as well as seven WHO staff – was held in April 2016 at WHO headquarters in Geneva, Switzerland. At this meeting, the working group created the framework for the implementation guide, by identifying three general 1 GUIDE TOOLKIT 04 1.6 ADAPTATION OF THE MEC/SPR GUIDANCE TO THE NATIONAL CONTEXT Making changes in the aesthetics and format of the guidance, as well as translation to local languages, are optional but potentially valuable steps in the process of adaptation. Tailoring guidance to the level of the service provider may also be appropriate depending on the setting. In addition, in some settings there may be a need for the addition of particular counselling messages or clarifications. The scientific content of the MEC or SPR, however, should generally remain unchanged when incorporated into national guidelines, as WHO recommendations are developed through a rigorous process of global research and review. Omission of portions of the guidance should generally be avoided in order to deliver evidence-based standards of the highest quality. Fidelity is essential to the implementation of the MEC and SPR guidance: family planning guidelines at the country level should adhere to WHO recommendations. Only in rare circumstances will changes to the WHO guidance be warranted, such as in countries where high- quality country-specific data indicate the need for variations and additions to the WHO recommendations. It is important to note that evidence-based country-specific alterations of WHO guidance may take years to finalize. Changes or additions to medical or counselling recommendations should be supported through evidence and research, without reliance on anecdotal, cultural or social factors. The evidence and process for deciding on these adaptations should be clearly documented in the guidance document. All classes of family planning methods should generally be included in the national guidelines, even if certain methods are currently unavailable. Method availability can change over time, and health systems should be encouraged through a variety of means to carry the full method mix. Adaptations at the national level provide essential feedback for improving and updating global guidance. While WHO headquarters does not need to review or approve these adaptations, WHO encourages countries to share them with WHO country and regional offices, so that these adaptations can be considered in the process of updating global guidance. For additional information, please see the Adaptation of Guidance Tool in the Implementation guide toolkit. goals for the guide: (i) to help countries take ownership of the guidance provided in the MEC and SPR, (ii) to improve the usability of the guidance, and (iii) to turn policy into practice. Next, with these goals in mind, a stakeholder meeting of the Implementing Best Practices (IBP) Consortium was held in Washington, DC, in August 2016, to gain inputs and insights from implementation experts and partners. Revisions to the draft implementation guide were subsequently reviewed with original working group members at a teleconference in November 2016, and again at a second in-person meeting with the working group, including members of IBP, in March 2017. At each of these meetings, participants discussed the definitions of “adoption” and “adaptation” in the context of the development of the implementation guide for the MEC and SPR. The term “adoption” in the context of local use of international guidelines has not been formally defined, but has been used informally to describe the direct incorporation of WHO-published tools, such as the WHO Medical eligibility criteria wheel for contraceptive use (referred to as “the MEC wheel”) (6), in local clinical settings. Based on the published document Introducing WHO’s reproductive health guidelines and tools into national programmes: principles and processes of adaptation and implementation, adaptation “transforms an externally developed guideline or tool into an accepted product that fits a particular country’s or region’s needs, circumstances, and context. It may include the updating or revision of existing national guidelines and tools” (7). The MEC discusses adaptation of guidance as well: “The guidance in this document is intended for interpretation at country and programme levels in a manner that reflects the diversity of situations and settings in which contraceptives are provided. While it is unlikely that the classification of categories in this document would change during this process, it is very likely that the application of these categories at country level will vary. In particular, the level of clinical knowledge and experience of various types of providers and the resources available at the service-delivery point will have to be taken into consideration (3).” In the course of the working group meetings and in conjunction with our implementation science experts, the working group determined that any use of WHO guidance in a country context will be an “adaptation” from an implementation science perspective, as the guidance will always be adapted for use in the local setting, even if the WHO-published materials (e.g. the MEC wheel) are used without modifications. Thus, in the body of this document, the term “adaptation” will be used and defined as a process to incorporate the most updated WHO MEC and SPR guidance into national family planning guidelines, and to implement these evidence-based guidelines in practice on the ground. With further revisions and consultation with colleagues and experts, these definitions may be revisited in the future. 1 05 2 2. INTEGRATING WHO FAMILY PLANNING GUIDANCE INTO NATIONAL FAMILY PLANNING GUIDELINES: RECOMMENDED PROCESS BOX 2: FRAMEWORK FOR THE STAGES OF IMPLEMENTATION: OVERARCHING PRINCIPLES FROM IMPLEMENTATION SCIENCE AS RELATED TO INTEGRATION OF THE MEC AND SPR INTO NATIONAL FAMILY PLANNING GUIDELINES EXPLORATION INSTALLATION INITIAL IMPLEMENTATION FULL IMPLEMENTATION Full implementation stage: Full implementation of MEC/SPR guidance through national family planning guidelines. The processes and procedures to support the new guidelines are in place. The system has largely been adjusted to accommodate and support the changes. Initial implementation stage: Roll-out of revised national family planning guidelines. During this initial implementation stage, existing processes within a setting must be altered, leading to changes in organizational roles and functions as well as changes to the structures that accommodate and support the work of service providers. In this stage, updated family planning guidelines and materials are being put to use. Intensive coaching of practitioners by local implementation team members is paramount. Problems may emerge and it is necessary for the team to develop and engage in strategies to promote continuous improvement and rapid-cycle problem-solving (Box 3). Measured metrics from monitoring and evaluation should be used to assess the quality of implementation, identify problems and solutions, and inform decision-making. Installation stage: Launching practical preparations for a revised national family planning programme. The preparations during this stage include securing resources, developing adapted guidelines and conducting capacity-building to facilitate the initial implementation. Communication protocols need to be defined and developed, financial and human resources should be secured, and budgets must allocate funding for supplies and personnel. In addition, those who are expected to implement the guidelines should receive training and support. Therefore, training and coaching programmes for developing the knowledge, skills and abilities of educators, practitioners and front-line health workers in family planning should be conceptualized, created and operationalized. Exploration stage: Mapping the current country family planning guidelines and status of their use. The overarching goal of the exploration stage is to assess the country’s need and readiness for implementation of the MEC and SPR guidance. The exploration stage activities are essential to ensure efficiency and timeliness of the implementation process. SUSTAINABILITY Sustainability: Programmatic sustainability needs to be considered during all stages of implementation. This involves continuing to provide timely and effective training, coaching, monitoring and evaluation. Source: The National Implementation Research Network’s Active Implementation Hub [website], 2017 (8) 06 MAPPING THE CURRENT COUNTRY FAMILY PLANNING GUIDELINES AND THE STATUS OF THEIR USE The overarching goal of the exploration stage is to assess the country’s need and readiness for implementation of the WHO MEC and SPR guidance. The exploration stage activities are essential to ensure efficiency and timeliness of the implementation process (8). To determine the capacity, schedule and budget for implementation. This process will begin with country-level mapping of the relevant key stakeholders, resources and personnel as well as the family planning guidelines and standards documents, which should be conducted by the ministry of health (MOH) and/or programme managers (see Stakeholder Mapping Guide in the Implementation Guide Toolkit). After the mapping process, WHO recommends conducting a readiness assessment to determine next steps for the MEC/SPR guidance to be implemented (see Readiness Assessment Tool in the Implementation Guide Toolkit). DEVELOPING AN IMPLEMENTATION TEAM The national implementation team, under the leadership of the MOH, should include key stakeholders in reproductive health and family planning service delivery. These stakeholders may represent the public health department of the MOH, the WHO country office, medical training institutions, partner NGOs and faith-based organizations, and may include private sector health-care providers and community health workers. To develop the team, activities may include the following: GOALS OF THE EXPLORATION STAGE ACTIVITIES OF THE EXPLORATION STAGE To educate leaders in family planning policy- making, programme management and service delivery about the updated MEC and SPR guidance. To compare the current national family planning guidelines and other resources with the updated MEC and SPR guidance, and determine where there is consistency and where there are inconsistencies and gaps. To examine the degree to which incorporation of the MEC and SPR guidance will respond to the sexual and reproductive health and rights needs of the country. Assess if there are personnel to serve as members of implementation teams, and determine criteria for inclusion in the implementation team (see Stakeholder Mapping Guide in the Implementation guide toolkit). Begin to develop implementation teams at the country level and at the regional/district and programme levels. Understand the priorities of the stakeholders and their motivations regarding adaptation and implementation of the MEC and SPR guidance. Arrange an implementation team meeting with stakeholders. The country, via the MOH or other leading government body, should determine the scope of initial implementation, in terms of both activities and location. Using existing WHO guidance and tools (e.g. the MEC wheel) may require investment of fewer resources than revising current country guidelines or creating new tools that have minor differences from the WHO tools. 1 2 3 4 RE SOURCES T EAMS MEET ST A K EH OL DER PRIO R IT IE S 2.1 EXPLORATION 07 1. INTRODUCTION Introduce the updated MEC and SPR and present a summary of the steps taken for their development. 2. BRIEFING Brief the stakeholders about the basis for the integration of the MEC/SPR guidance and its necessity for the improvement of the country programme, and ensure that they have a clear understanding of goals and scope of the process. 3. COMMITMENT & CAPACITY Determine the country’s commitment to and capacity for incorporating the MEC/ SPR guidance. 4. GOALS Determine clear country goals for incorporating the MEC/SPR guidance (see Measuring Adherence to Guidance Tool in the Implementation guide toolkit). 5. READINESS ASSESSMENT Initiate a needs assessment that compiles current national family planning guidelines, tools and other resources and compares these with the updated MEC and SPR guidelines, including an evaluation of the guidelines on family planning service delivery and counselling. Determine where there is consistency and where there are inconsistencies and gaps in national guidelines/resources as compared with WHO guidance (see Readiness Assessment Tool in the Implementation guide toolkit). 6. PROCEDURES & RESOURCES Determine the procedures and resources (including financial resources) that need to be in place in order to carry out installation of the revised guidance. 2. BRIEFING 1. INTRODUCTION 3. C O M M IT M E N T & C A PA C IT Y 4. G O A L S AS SE SS M EN T 5. NE ED S 6. PROC EDU RES & RESO URC ES 2 CONDUCTING A STAKEHOLDER MEETING If a large-scale implementation activity is planned, arrange to conduct a multi-day meeting of previously identified stakeholders, to explore and begin integration of the MEC/SPR guidance (see example of a stakeholder meeting report provided in the Implementation guide toolkit). The following activities can be conducted as part of the meeting. 08 The installation stage of implementation involves practical preparations to initiate revisions to the national family planning guidelines based on the MEC/SPR guidance. Communication protocols need to be defined and developed, financial and human resources should be secured, and budgets should allocate funding for supplies and personnel. In addition, those who are expected to Determine measurable objectives for incorporating MEC/SPR guidance into national family planning guidelines and materials, including a schedule for meeting the objectives (see Measuring Adherence to Guidance Tool in the Implementation guide toolkit). Determine the process by which MEC/ SPR guidance can be incorporated into national family planning guidelines and materials, including a process for updating training tools. Create a mechanism to continually assess and improve family planning service delivery. • Develop a monitoring and evaluation programme for adherence to the MEC/ SPR guidance (see the Measuring Adherence to Guidance Tool in the Implementation guide toolkit), keeping in mind principles of “rapid-cycle problem- solving” (see the Plan-Do-Study-Act (PDSA) Tool in the Implementation guide toolkit, and Box 3). • Create a mechanism to periodically revise national guidelines to assure alignment with ongoing revisions to the MEC and SPR. Revise national family planning guidelines, tools and resources in accordance with goals and objectives. Ensure consistency between the new family planning guidelines and service- delivery guidelines and guidelines in other sectors by making revisions as needed (e.g. maternal and newborn health, HIV and task shifting). 1. DETERMINE OBJECTIVES & PROCESSES 2. REVISE EXISTING RESOURCES 3. ESTABLISH CONSISTENCY implement the guidance should receive training and support. Therefore, training programmes for educators, practitioners and front-line health workers in family planning should be developed. Many elements of the installation stage may be initiated during the stakeholder meeting in the previous exploration stage (8). LAUNCHING PRACTICAL PREPARATIONS FOR INTRODUCTION OF REVISED NATIONAL FAMILY PLANNING GUIDELINES 2.2 INSTALLATION ACTIVITIES OF THE INSTALLATION STAGE 09 GOALS OF THE INSTALLATION STAGE Members of these teams will be relevant local personnel including service-delivery providers and staff who will offer training on the guideline changes, supply chain managers, family planning officers, monitoring and evaluation experts, and primary implementation personnel (such as developers of evidence-based programmes, staff of agencies and NGOs who assist in implementing evidence-based programmes, and members of local groups that have expertise in quality- improvement methods). Select a target population, location or district for initial implementation, to inform future processes for full implementation. Assess the current curriculum for pre-service and in-service training at the initial implementation site. Determine the process by which the MEC/SPR guidance can be incorporated into family planning service-delivery norms and procedures at the initial implementation site. This task may be appropriate for a local implementation team (see right). Determine processes for monitoring and evaluation of the initial implementation stage for the r evised guidelines. 4. DEVELOP A COMMUNICATION PLAN Develop a communication plan to describe the implementation objectives and processes (see the meeting report example provided in the Implementation guide toolkit). Identify effective routes of communication among policy-makers, programme managers and front-line health workers. Identify and establish clear lines of communication with local implementation leaders who will take responsibility for local change. 6. FORM LOCAL IMPLEMENTATION TEAMS 5. IDENTIFY TARGET GROUP Finalize which country guidelines, tools and resources should be updated, and determine goals and processes for implementing the updates. Determine quality-improvement indicators to assess adherence to guidelines and improvement in family planning service delivery. Develop a mechanism to periodically review and revise national guidelines and tools to ensure alignment with ongoing revisions to the MEC and SPR. 1 32 2 10 • Disseminate a memorandum or government circular summarizing any changes in the family planning guidelines. • Publish updated national family planning guidelines and/or tools. • Arrange presentations at training institutions (such as medical or nursing schools), teaching hospitals, and professional medical, midwifery and nursing societies. • Arrange webinars, seminars and workshops to provide training for MOH staff and partners on the ground. • Ensure media involvement through a press release and by working with local media groups. • Develop and plan for in-service training and dissemination of materials at family planning service-provision settings. • See Dissemination Tool in the Implementation guide toolkit Incorporate coaching on rapid-cycle problem-solving, which allows effective movement from the initial implementation stage to the full implementation stage and, eventually, to sustainability (see Box 3 and the Plan- Do-Study-Act (PDSA) Tool in the Implementation guide toolkit). 1. CREATE A CLEAR DISSEMINATION STRATEGY 2. INCORPORATE RAPID-CYCLE PROBLEM SOLVING In this stage, updated family planning guidelines and materials are being put to use. Often programmes will falter at this stage, falling back on the prior status quo. Intensive coaching of practitioners by local implementation team members is paramount during this stage. Problems may emerge and it is necessary for the team to develop and engage in strategies to promote continuous improvement and rapid-cycle problem-solving (Box 3). During this initial implementation stage, existing processes within a setting must be altered, leading to changes in organizational roles and functions as well as changes to the structures that accommodate and support the work of service providers (8). ROLL-OUT OF REVISED NATIONAL FAMILY PLANNING GUIDELINES 2.3 INITIAL IMPLEMENTATION ACTIVITIES OF THE INITIAL IMPLEMENTATION STAGE 11 Partner with local implementation teams to roll out the updated guidelines in the selected location(s) or population(s) for initial implementation. Local implementation may begin with assessment of local tools, training of trainers, and cascade training of service providers. The Training Resource Package for Family Planning website (https://www.fptraining.org/) can be used to aid in these activities (9). Monitor and evaluate the roll-out of the updated guidelines in the selected location(s)/population(s) to identify barriers and facilitators. This may occur in the following ways: • Standardized reporting of the usability of guidance and tools • Monitoring compliance with the MEC/SPR guidance (see the Dissemination Tool and Measuring Adherence to Guidance Tool in the Implementation guide toolkit) • Documentation of best practices • Documentation of pre-specified implementation outcomes 3. PARTNER WITH LOCAL IMPLEMENTATION TEAMS 4. MONITOR & EVALUATE GOALS OF THE INITIAL IMPLEMENTATION STAGE To ensure widespread knowledge and dissemination of guideline changes. To revise existing processes within a setting as driven by guideline changes. To promote the use of the updated family planning guidelines in selected settings. To create changes in organizational roles, functions and structures to accommodate and support new workflows created by revisions to the national family planning guidelines. 1 2 3 4 2 The full implementation stage occurs once the new family planning guidelines become fully integrated into organizational and provider practices, policies and procedures. The goal is for the new guidelines to become “standard practice”. During full implementation, monitoring GOALS OF THE FULL IMPLEMENTATION STAGE and evaluation should continue to occur at a local level, as more staff members participate and turnover occurs. In general, full implementation of a change is difficult to achieve and sustain without the necessary implementation supports (8). To have in place country-wide processes and procedures to support the use of the updated national family planning guidelines, consistent with the MEC/SPR guidance. To support country-wide changes in policies, procedures and mechanisms for sustainability, and for monitoring and evaluation of the implementation of the new guidelines and tools. 1 2 FULL IMPLEMENTATION OF MEC/ SPR GUIDANCE THROUGH NATIONAL FAMILY PLANNING GUIDELINES 2.4 FULL IMPLEMENTATION ACTIVITIES OF THE FULL IMPLEMENTATION STAGE “The goal is for the new guidelines to become ‘standard practice’.” The activities of the full implementation stage are geared towards standardizing the new guidelines in everyday practice. As such, constant feedback loops are at play as updates are incorporated and communicated, adherence and dissemination are tracked, implementation is evaluated, and relationships are fostered with local implementation teams. 12 1. INCORPORATE UPDATES & REVISIONS Ensure that any new or revised recommendations that are published in updated editions of the MEC or SPR, which are included as a table in each published version of the MEC and SPR, are incorporated into the national guidelines, policies and standards. 2. DISSEMINATE REVISIONS Ensure that any updates to the MEC and/or SPR guidance are disseminated though a similar process as described for the initialupdated guidelines. Updates to MEC/SPR guidance may be distributed through an accelerated process that does not require the resources of a large stakeholder meeting, but which may actively involve the original and new implementation team members. Define a mechanism to monitor and report any changes in the MEC/SPR guidance. (See Dissemination Tool in the Implementation guide toolkit) • Designate a person or role to stay abreast of changes in MEC/ SPR guidance. • Periodically review the WHO Reproductive Health and Research webpage for new items that are revised or developed2. • Subscribe to HRP News using the link on the above-mentioned webpage. 3. TRACK ADHERENCE Track fidelity metrics of adherence to the MEC/SPR guidance (see Measuring Adherence to Guidance in the Implementation guide toolkit). 4. TRACK DISSEMINATION Use a measurement plan to track dissemination of, adherence to, and widespread use of the updated national family planning guidelines (see Dissemination Tool in the Implementation guide toolkit). 5. FEEDBACK ON IMPLEMENTATION Create a feedback mechanism by which front-line providers can be evaluated on the implementation of new family planning guidelines (see Feedback and Audit Tool in the Implementation guide toolkit). 6. FOSTER RELATIONSHIPS Continue to foster local relationships with local implementation team leaders and members who will take responsibility for local implementation of the new guidelines. 13 2. DISSEM INATE REVISIO NS 1. INCORPORATE UPDATES &REVISIONS 3. T R A C K A D H E R E N C E 4. T R A C K 5. F EE DB AC K O N 6. FOS TER RELATIO NSH IPS IM PL EM EN TA TI O N D IS S E M IN A T IO N FULL IMPLEMENTATION STAGE PROCESS OVERVIEW 2 2Available at: http://www.who.int/reproductivehealth/en/ Sustainability planning and related activities need to be an active component of every stage of implementation, and attention to both financial and programmatic sustainability is necessary. Financial sustainability involves ensuring that the funding streams for implementation of national family planning guidelines are established, adequate and sustainable. Potential funding streams should account for personnel time costs, dissemination costs, and costs of monitoring and evaluation. Concordant improvements to optimize the supply chain for the full range of contraceptives, to support delivery of an appropriate method mix, is also an important consideration, although 2.5 SUSTAINABILITY OF THE MEC/SPR GUIDANCE IN NATIONAL FAMILY PLANNING GUIDELINES this is beyond the scope of this guide. Programmatic sustainability involves ensuring that the implementation infrastructure is established, reliable, effective and sustainable. The system needed to ensure continued high-quality implementation includes plans and activities (i) for continuing to provide timely and effective training and coaching, (ii) for conducting ongoing measurement processes in support of data-driven decision-making for continuous improvement and problem-solving, and (iii) for ensuring that policies and procedures continue to support and facilitate the use of revised guidelines (8) Any stage of the implementation process may involve changes to the status quo. At these times, problems may emerge. In particular, the Initial Implementation stage may involve the need to alter existing processes, functions, roles or structures supporting service provision. Rapid-cycle problem solving, detailed in Box 3 on the following page, can assist practitioners to avoid maintaining old habits and to improve their adherence to the MEC/SPR guidance. EXPLORATION INSTALLATION INITIAL IMPLEMENTATION FULL IMPLEMENTATION “Financial sustainability involves ensuring that the funding streams for implementation of national family planning guidelines are established, adequate and sustainable.Programmatic sustainability involves ensuring that the implementation infrastructure is established, reliable, effective and sustainable.” SUSTAINABILITY 2 14 15 BOX 3: RAPID-CYCLE PROBLEM-SOLVING: USING A PRACTICE–POLICY COMMUNICATION CYCLE FOR INCORPORATION OF REVISED FAMILY PLANNING GUIDELINES EXAMPLE: OFFERING IMPLANTS TO POSTPARTUM AND BREASTFEEDING WOMEN Source: The National Implementation Research Network’s Active Implementation Hub [website], 2017 (8) Rapid-cycle problem-solving supports the purposeful process of change, and is based on the Plan-Do-Study-Act (PDSA) process. THE PDSA PROCESS CONSISTS OF FOUR PHASES: The practice–policy communication cycle is one method to promote country-level implementation that incorporates the PDSA process. Changes in family planning policy require support from leadership, policy-makers and partners, and practice–policy communication cycles ensure that while policies are implemented to impact practice, there is feedback to policy-makers regarding intended and unintended impact at the practice level. Implementation teams, created during the first (exploration) stage of POLICY: Contraceptive implants should be offered to breastfeeding women less than six weeks after delivery PLAN: Offer contraceptive implants to all women, whether they are breastfeeding or not after childbirth. Develop and conduct a structured teaching session for service providers that reviews changes in the 2015 Medical eligibility for contraceptive use, fifth edition, emphasizing the lifting of the restriction on progestin-only implants immediately postpartum. Ensure that training, coaching and performance-assessment measures are in place, that leadership is engaged for problem-solving, and that there is organizational alignment. DO: Enforce the policy that implants are to be offered to breastfeeding women at any time after delivery. STUDY: In the month after the training, assess the proportion of breastfeeding women less than six weeks postpartum (i) who are offered and (ii) who accept the progestin-only implant. Compare these to pre-training PLAN Identify barriers or challenges, specify the plan to move programmes forward and the outcomes that will be monitored DO Carry out the strategies or plan. STUDY Use the measures identified during the planning phase to assess and track progress. ACT Make changes to the next iteration of the plan to improve implementation. proportions. Assess the fidelity to the use of the guidelines and what is needed to move forward. It is found that the supply of implants is limited in the immediate postpartum period. ACT: If no changes are seen in the proportion of breastfeeding women less than six weeks postpartum who are (i) offered or (ii) accepting the contraceptive implant, address concerns or barriers with practice staff. Provide the support needed to ensure fidelity and progress in moving to full implementation. Take action (e.g. additional coaching, training on implant placement, review of evidence) based on provider feedback. Address and resolve the supply chain barrier by ordering additional implants. POLICY CHANGE: Ordering schedule for implants is revised to support the new practice recommendation. Repeat the PDSA practice–policy communication cycle to check for other barriers to policy implementation. implementation, should be tasked with promoting, developing and negotiating the mechanisms for such communication. Bidirectional communication is critical to ensuring that policy-makers understand the impact of their efforts, and that those on the front line have the support they need. Good policy enables good practice, but practice also must inform policy (see Plan-Do-Study-Act (PDSA) Tool and Improvement Cycles Tool in the Implementation guide toolkit). 2 Implementation of the WHO Medical eligibility criteria for contraceptive use (MEC) and Selected practice recommendations for contraceptive use (SPR) guidance involves a process that incorporates not only revision of the current national guidelines in line with latest versions of the MEC and SPR and distribution of these revised documents, but also efforts to change systems and provider practices. Implementation of a country-level family planning programme is a complex, multidisciplinary process that requires engagement from multiple stakeholders. 3. CONCLUSION Successful country-level implementation of the MEC and SPR builds a strong foundation of knowledge and good clinical practice for providing family planning services. Implementation of the MEC and SPR, along with the many other factors that contribute to high-quality family planning services, will improve maternal and child health outcomes and allow countries to be one step closer to achieving the Sustainable Development Goals and linked national health initiatives, thereby improving the health of societies in general. 3 “Successful country-level implementation of the MEC and SPR builds a strong foundation of knowledge and good clinical practice for providing family planning services.It will improve maternal and child health outcomes and allow countries to be one step closer to achieving the Sustainable Development Goals.” 17 The Implementation guide toolkit which accompanies this implementation guide can be found online at www.who.int/ reproductivehealth/mec-spr-implementation-guide- toolkit/en/ The following WHO published guidance and websites contain useful tools and links for successful implementation of family planning guidelines locally: • Medical eligibility criteria for contraceptive use, fifth edition (2015): http://www.who.int/reproductivehealth/ publications/family_planning/MEC-5/en/ • Selected practice recommendations for contraceptive use, third edition (2016): http://www.who.int/ reproductivehealth/publications/family_planning /SPR-3/en/ 4. RESOURCES AND SUPPORT IN THE IMPLEMENTATION OF MEC/SPR GUIDANCE 1. Becker D, Koenig M, Kim YM, Cardona K, Sonenstein FL. The quality of family planning services in the United States: findings from a literature review. Persp Sex Reprod Health. 2007;39(4):206–15. doi:10.1363/3920607. 2. Bruce J. Fundamental elements of the quality of care: a simple framework. Stud Fam Plann. 1990;21(2):61–91. 3. Medical eligibility criteria for contraceptive use, 5th edition. Geneva: World Health Organization; 2015 (http://www.who.int/reproductivehealth/publications/ family_planning/Ex-Summ-MEC-5/en/, accessed 29 September 2017). 4. Selected practice recommendations for contraceptive use, 3rd edition. Geneva: World Health Organization; 2016 (http://www.who.int/reproductivehealth/ publications/family_planning/SPR-3/en/, accessed 29 September 2017). 5. Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation research: a synthesis of the literature. Tampa (FL): University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network; 2005. 5. REFERENCES • Ensuring human rights in the provision of contraceptive information and services: guidance and recommendations (2014): http://www.who.int/ reproductivehealth/publications/family_planning/ human-rights-contraception/en/ • Ensuring human rights within contraceptive service delivery: implementation guide (2015): http://www.who. int/reproductivehealth/publications/family_planning/hr- contraceptive-service-delivery/en/ • WHO Sexual and Reproductive Health and Rights: Interactive Tools [website]: http://srhr.org/ • The Training Resource Package for Family Planning [website]: https://www.fptraining.org 6. Medical eligibility criteria wheel for contraceptive use. Geneva: World Health Organization; 2015 (http://www. who.int/reproductivehealth/publications/family_planning/ mec-wheel-5th/en/, accessed 29 September 2017). 7. Introducing WHO's sexual and reproductive health guidelines and tools into national programmes: principles and processes of adaptation and implementation. Geneva: World Health Organization; 2007 (http://www.who.int/ reproductivehealth/publications/general/RHR_07_09/ en/, accessed 20 September 2017). 8. The National Implementation Research Network's Active Implementation Hub [website]. Chapel Hill (NC): University of North Carolina at Chapel Hill's FPG Child Development Institute; 2017 (http://implementation.fpg.unc.edu/, accessed 20 September 2017). 9. The Training Resource Package for Family Planning [website]. Baltimore (MD): Johns Hopkins University; 2017 (https://www.fptraining.org, accessed 26 September 2017). 4 5 ISBN 978 92 4 151357 9

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