Myanmar was the second country site for the GREAT Network’s in-country guideline prioritization and implementation planning work. In June 2014, local stakeholders including clinicians, healthcare providers, healthcare administrators, researchers/academics, non-governmental organizations, policymakers, and professional associations from Myanmar gathered as participants of a two-day workshop that involved focus group discussions followed by a prioritization meeting. Informed by joint consultations with the World Health Organization (WHO) and the Department of Health Myanmar, the 2012 WHO OptimizeMNH guideline on task shifting in maternal and newborn health was selected as a priority for implementation in Myanmar.
Key objectives of the in-person workshop included:
- To identify barriers and facilitators to the implementation of the task shifting guidelines in Myanmar; and
- To develop a cross-cutting, multi-level implementation strategy to improve the use of the guidelines.
Multiple methods were used to collect data on priorities, barriers and facilitators, as well as to determine potential implementation strategies for the task shifting guideline in Myanmar. Primary data collection occurred during an in-country two-day workshop involving focus group (FG) discussions, a ranking exercise, and small and large group discussions to explore barriers and facilitators, identify guideline priority areas, and develop action-oriented and tailored implementation strategies. Prior to the workshop, a survey was administered to inform workshop proceedings.
The process of selecting priority maternal and newborn health (MNH) recommendations and exploring barriers and facilitators to implementing the task shifting guideline yielded rich information for implementation planning in Myanmar.
- Participants in all FGs discussed issues at the level of the healthcare system, which included various factors related to the widespread conditions of the Myanmar context that can affect the implementation of the task shifting guidelines. These factors include shortage of midwives (MWs) and auxiliary midwives (AMWs), available resources, accountability and monitoring, and policies and political context.
- Issues at the level of the healthcare provider were prevalent, where several barriers related directly to the AMWs, and MWs, physicians and clinicians were described. Specific factors discussed by FG participants include role and capacity of AMWs and MWs; education and quality of training; willingness, buy-in and motivation; and relationships between health cadres.
- Finally, issues at the level of the patient/community were described and includedcommunity/patient perceptions of AMW and MW roles and cultural practices and health-seeking behaviours.
The ranking exercise resulted in a list of task shifting recommendations that were deemed feasible to implement according to workshop participants. Within the small group discussions, several recommendations to overcome barriers were suggested as the building blocks for an action plan to guideline implementation.
The findings of the pre-workshop survey aligned with those of the in-person workshop; both data collection methods helped to shape concrete strategies for moving forward on selected guideline recommendations. The most salient points that emerged from the pre-workshop and workshop activities were:
- Task shifting should be considered across the system, where tasks can be shifted vertically and laterally in a manner that is feasible and suitable to Myanmar’s largely rural context.
- Proper training and education of multiple cadres of health care workers is essential to optimal implementation of the task shifting guidelines.
- Overall, training can increase trust and buy-in across all levels, and can improve perceptions about the roles of midwives (MWs) and AMWs.
- Myanmar may consider reviewing and defining the AMW role in terms of how individuals are selected, trained, retained, regulated, and supervised in order to make positive and sustainable changes to how maternal care is delivered, especially in rural and remote settings.
- Guideline implementation requires policymaker buy-in and a push for changes at the policy level, including:
- Engaging policymakers and professional organizations with evidence briefs;
- Revising policies related to drug administration and distribution;
- Financially committing to provision of drugs and equipment to AMWs; and
- Instituting regulatory oversight of AMWs.
Many of the barriers and facilitators discussed regarding the guidelines are applicable to other priority areas; therefore, these findings can inform and be integrated into future barrier and facilitator assessments conducted for additional guideline implementation initiatives in Myanmar.
For full details about this project please read our final report.