Ethiopia is the fifth country site for the GREAT Network’s in-country guideline prioritization and implementation planning work. An in-country workshop was held in May 2015 in Bishoftu, Ethiopia to determine key recommendations that will inform the development of a multi-level implementation strategy for improving use of the WHO guidelines nationally. Recommendations resulted from:
1) Identifying barriers and facilitators to the implementation of the guideline in Ethiopia; 2) Identifying the most important and feasible recommendations for implementation; and 3) Providing suggestions for potential implementation strategies based on the barriers and facilitators identified, and the perceived feasibility of implementation.
A mixed methods approach was used to collect data on priorities, barriers, facilitators, and potential implementation strategies for the WHO recommendations on PPH in Ethiopia. Prior to the workshop, a survey was administered to inform workshop proceedings. Primary data collection occurred during the in-country two-day workshop; this involved focus group discussions, an individual ranking exercise, and small and large group discussions. The workshop aimed to explore barriers and facilitators to guideline implementation; identify guideline priority areas; and develop potential implementation strategies to fit the local context.
Fifty three stakeholders participated in the pre-workshop survey and nineteen stakeholders participated in the in-person workshop. Stakeholders represented multiple disciplines from diverse geographic regions and levels of the health care system including: health care administrators, policymakers, nongovernmental organization staff, representatives from professional associations, frontline health care providers (e.g., physicians and midwives), and health system researchers/academics.
Findings from the pre-workshop survey identified ‘use of uterotonics’ as the highest priority (66% of respondents) of the four clinical areas in which the recommendations of the Prevention and Treatment of PPH guideline were grouped. A total of five recommendations received a median score of 5 (5= extremely well implemented), when respondents were asked how well the guideline recommendations were currently being implemented in their individual settings from their experience.
Findings from the focus group discussions described issues at the level of the health care system, which included factors related to policies and wider systemic conditions in Ethiopia that can affect 5 implementation of the WHO guideline recommendations. These factors included: access to resources (e.g., drugs, supplies, personnel, facilities); drug procurement, distribution, management; data collection and monitoring; policies and incentives; readiness for change; and guidelines and protocols. Issues at the level of the health care provider that may affect guideline implementation were prevalent, and included: beliefs, attitudes, and buy-in about the use of guideline recommendations; knowledge and skills needed to implement the guidelines; training and supportive supervision around guideline implementation; and role definition. Finally, issues at the level of the patient/community that may affect guideline implementation included: traditional beliefs; knowledge and awareness; and access to health care services.
The ranking exercise resulted in an assessment of the feasibility of 11 guideline recommendations that were deemed to be priorities in Ethiopia by participants. Within subsequent small group discussions, multiple implementation strategies were suggested to overcome barriers.
Informed by the findings of the pre-workshop and workshop activities, the following ten recommendations have been developed to guide next steps of guideline implementation in Ethiopia:
- Recommendation #1: Create a guideline implementation working group (WG) as a sub-group of the Federal Ministry of Health’s maternal health case team. This guideline implementation WG should be multi-disciplinary and include representation from multiple levels.
The following six recommendations are intended for operationalization by the guideline implementation WG:
- Recommendation #2: Adapt the WHO maternal health guideline on Prevention and Treatment of PPH for the Ethiopian context using the ADAPTE process.
- Recommendation #3: Create standard protocols on how to implement the guideline recommendations and distribute to facilities for onsite guidance. Protocols should be userfriendly, ready-to-use, and visible (e.g., posted on wards) to act as reminders for HCWs.
- Recommendation #4: Select and implement priority clinical indicators as part of a monitoring and evaluation strategy on PPH prevention and management to enable systematic and standardized assessment of guideline implementation.
- Recommendation #7: Design and conduct a process and outcome evaluation of the guideline implementation approach. 6 The following three recommendations are intended for the guideline implementation WG in partnership with other key stakeholders (e.g., professional associations, other ministries, independent evaluators, etc.):
- Recommendation #5: Establish a mentorship program at the facility level between junior and senior HCWs to provide technical support and supportive supervision on implementation of the guideline recommendations protocols.
- Recommendation #6: Establish an interdisciplinary quality improvement team (e.g., including physicians, midwives, administrators) at each health care facility to identify priority areas for practice improvement based on the clinical indicators identified in recommendation #4. Quality improvement teams should develop and monitor quality improvement strategies for the priority areas at the facility level.
- Recommendation #8: Identify strategies to improve and standardize the benefits package offered to HCWs across all regions so that HCWs in rural regions receive the same compensation package as HCWs in urban regions.
- Recommendation #9: Conduct a process evaluation of the Health Extension Worker Program to improve functioning of the program in regions where it is not optimally working and share lessons learned from those regions where the program is working.
- Recommendation #10: Evaluate the Maternity Waiting Home initiative, which is currently being used in some remote areas to mitigate barriers experienced with the transportation to health facilities for deliveries during the rainy season. Key evaluation outcomes to consider could include: increased number of women giving birth at health care facilities, decreased incidence of PPH cases, decreased incidence of maternal deaths from PPH cases). If successful outcomes are demonstrated, consider scale up of this program.
Many of the barriers, facilitators, and resultant implementation strategies identified regarding the prioritized recommendations are applicable to other priority areas in health care; therefore, findings from this report can inform and be integrated into future barrier and facilitator assessments and guideline implementation planning initiatives in Ethiopia and in similar LMICs.
For full details about this project please read final report.