Process for development of the toolkit

Jhpiego adopted a consultative approach to develop the key elements of the toolkit. Jhpiego organized a side event during the Global Maternal and Newborn Health Conference held in Mexico in November 2015 to first discuss the concept of the toolkit amongst a core group of key stakeholders in quality of care for the private sector. During this consultation, Jhpiego presented an outline of the toolkit. The group participants provided feedback on the structure and applicability of the toolkit.
With the intention of building upon the existing resources, Jhpiego did a landscape review of similar existing resources within and outside Jhpiego, including those from WHO, USAID, guidelines from the Government of India, and various professional organizations, as a first step in the process of the development of the toolkit. Available resources were reviewed for applicability to the developing country context.
With the background resources, Jhpiego held an international consultation meeting on the toolkit on December 11-12, 2015 in Delhi. The purpose of this meeting intended to initiate the development of a practical toolkit for improving quality of care during childbirth in the private sector, to validate findings from the landscape review, and to gather additional input from partners, various professional bodies, user segments, government representatives, and experts.
This consultation was attended by more than 45 participants from India and Uganda, representing development partners working with private sector healthcare providers, private practitioners from FOGSI, representatives from Association of Obstetricians and Gynaecologists of Uganda (AOGU), representatives from Governments of India and Uganda, professional association of obstetricians and nurses, and members of the National Accreditation Board of Hospitals (NABH).

Major objectives of the consultation were:

  • To reinforce and understand specific needs of private sector institutions in developing countries in order to improve the quality of care during childbirth;
  • To finalize the scope and components of the toolkit for standardizing care during childbirth in private sector institutions;
  • To define the outline of subcomponents of various toolkit modules; and
  • To finalize action‐plans and the schedule of activities for the final toolkit.

The participants reviewed the needs of the private sector for quality improvement and defined guiding principles for developing the toolkit. Additionally, they determined that the toolkit components should build upon, adapt, and upgrade existing available tools that have been found to be useful in similar contexts. It was also recommended that the toolkit should be user‐friendly, easy to access, adaptable, self‐explanatory, minimal resource intensive and based on global guidelines for standardization across nations. To facilitate further discussions, Jhpiego presented a draft outline of the toolkit to the participants which were endorsed by all participants.
Subsequently, the participants worked in smaller groups to define the components and sub-components of the toolkit and discussed the details of the proposed standards. One Jhpiego staff member was assigned to each group and tasked with the responsibility of coordinating the process of developing the toolkit components. The working groups also developed the plan of action and timelines for content development and finalization in preparation for the next consultation.
Following the consultation, based on the recommendations from the groups, Jhpiego prepared drafts of the components of the proposed toolkit, namely a set of quality standards and a customized training course outline, and quality measurement matrices, which were subsequently shared with the respective groups to obtain their feedback and input on the draft versions. As proposed, Jhpiego adopted an iterative approach by incorporating the feedback from the participants on a regular basis to further improve the tools. At each step of developing the toolkit, Jhpiego considered the group’s recommendations to develop one that is user‐friendly, easy to access, adaptable, self‐explanatory, minimal resource intensive and based on global guidelines for standardization across nations. Updated drafts of the toolkit components were shared on a regular basis to obtain more input and feedback for further refinement. Additionally, Jhpiego continued developing a repository of references and training material in order to complement the toolkit. The primary focus during this period was to finalize the set of clinical standards which would further help finalize the other two components, specifically the course outline and metrics.
As agreed upon in the first consultation, the final draft of the clinical standards was shared with the larger group by mid-February 2016 to obtain their feedback and further input by the end of February. The responses from the participants were considered and incorporated during the brainstorming sessions for refinement of the standards and other components prior to the second consultation.

On March 30-31, 2016, Jhpiego, in partnership with the FOGSI, hosted a second consultation on the toolkit for standardizing care during childbirth in private sector institutions with the following objectives:

  • To share the latest version of the toolkit with the stakeholders;
  • To finalize the content of various components of the toolkit;
  • To finalize an action plan with the schedule of activities for field testing of the toolkit; and
  • To finalize the action plan and way forward for final dissemination.

Similar to the first consultation, it included 48 participants representing the private practitioners from FOGSI and AOGU, representatives from the Governments of India and Uganda (GoI and GoU), various development partners working with the private sector healthcare providers in India and Uganda, and members of the National Accreditation Board of Hospitals (NABH).
Jhpiego presented the latest version of the toolkit to the participants. The group leaders, in their presentations, unfolded the layout and summary of various components of the toolkit. The vetting of the technical and clinical content of the toolkit’s sub-components was concluded by the working groups. The last recommendations on various components of the standards were recorded for inclusion in the final draft prior to field testing. The participants also engaged in discussions regarding the operational aspects of the toolkit including the methodology for use and Standard Operating Procedures (SOPs), and grouped some striking recommendations for finalizing the way forward for the field testing and the final roll-out plan of the toolkit.

The meeting concluded with development of a field testing plan and suggestions for the global dissemination of the toolkit. For the field testing of the toolkit, it was decided that:

  • Field testing in India will involve selected FOGSI facilities in Uttar Pradesh and Jharkhand. This will be carried out by the four Local Chapters: three in UP and one in Jharkhand (including assessment of at least three facilities: one self-assessment and two external facility assessments). In Uganda, the field testing will be carried out by PACE Uganda and other development partners (10 facilities each).
  • The user feedback would be collected based on qualitative questionnaires related to applicability, ease of use, objectivity of assessment and clear gap identification process on the standards, course outline description, and on metric and dashboards.
  • Jhpiego will also undertake in-house mock training on the ANC and PNC components.
  • The said field testing would be conducted by April 30, 2016.

After the second consultation, input and feedback from the participants was incorporated into the standards, and accordingly, changes were made in the course outline and quality measurement matrices. The finalized version of the toolkit was shared with the group to initiate the field testing along with the qualitative questionnaires related to applicability, ease of use, objectivity of assessment and clear gap identification process on the standards, the course outline description, and on metric and dashboards.
The toolkit was field tested in nine private sector facilities across two states (Uttar Pradesh and Jharkhand) in India. Out of these, Jhpiego facilitated testing in three facilities, and in the rest of the facilities, local FOGSI champions facilitated the testing. Qualitative user feedbacks were collected from the users. One important feedback was to present the standards in simpler forms. One potential solution discussed was to keep the standards and the standards-based assessment form separate (earlier these were presented in a single sheet). Users also recommended slightly modifying the verification methodology for standards-based assessment tool. Course outlines were generally found to be suitable to facility needs. A few content related suggestions were made that were included. Modifications were also suggested in the data collection and collation tools. Jhpiego reviewed these suggestions and discussed them with the group leaders for potential solutions. Most of the design related suggestions were agreed to. Appropriate content suggestions were accepted; however, those that deviated from the normative guidelines were not included in consultation with the group members. Data collection tools and metrics were revised based upon relevant suggestions. The final toolkit was reviewed again for ease of presentation, correct technical content, and inclusion of relevant implementation information.

List of participants in the toolkit development process:

S No. Name Organisation
1 Leila Varkey Centre for Catalytic Change
2 HemaDivakar Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
3 Sadhana Gupta Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
4 Priti Kumar Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
5 Nevidita Dutta Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
6 MeeraLakhtakia Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
7 Alok Sharma Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
8 ShiviRawat Hindustan Latex Family Planning Promotion Trust (HLFPPT)
9 Anamika Pandey Hindustan Latex Family Planning Promotion Trust (HLFPPT)
10 MeenakshiDikshit Population Services International (PSI)
11 SudhirMaknikar John Snow International (JSI)
12 Dinesh Baswal Ministry of Health and Family Welfare, Government of India
13 P. Krishna Kumari MSD for Mothers India
14 SaiSubhasreeRaghavan Solidarity and Action Against the HIV Infection in India (SAATHI)
15 Varun Solidarity and Action Against the HIV Infection in India (SAATHI)
16 Anita Deodhar Trained Nurses Association of India (TNAI)
S No. Name Organisation
17 Evelyn P. Kannan Trained Nurses Association of India (TNAI)
18 Sangamitra Trained Nurses Association of India (TNAI)
19 SharmilaNeogi United States Agency for International Development (USAID)
20 Anuradha Jain United States Agency for International Development (USAID)
21 Mahesh Srinivas Pathfinder International, India
22 Mirazzuddin Ansari Pathfinder International, India
23 Gayatri V. Mahindroo National Accreditation Board of Hospitals (NABH), India
24 Vikrant Prabhakar ACCESS HEALTH
25 Sujatha Rao ACCESS HEALTH
26 Ajay Gambhir National Neonatology Forum (NNF)
27 Krishan Kumar Population Services International
28 Milly N Kaggwa Program for Accessible Health Communication and Education (PACE),Uganda
29 Anthony K Mugasa Ministry of Health, Uganda
30 Frank M Kaharuza Association of Obstrticians and Gynaecologists of Uganda (AOGU)
31 HasifahNalukwago ProFam UGANDA
32 TonnyKapsandui Jhpiego, UGANDA
S No. Name Organisation
33 Akhil K. Sangal National Neonatology Forum (NNF), India
34 Miriam Namugeere Ministry of Health, Uganda
35 ParvezMenom Jhpiego, India
36 SaiBarath Jhpiego, India
37 Renu Pandey Jhpiego, India
38 Suranjeen Prasad Jhpiego, India
39 Meshach Kujur Jhpiego, India
40 Dinesh Singh Jhpiego, India
41 Rashmi Asif Jhpiego, India
42 Bulbul Sood Jhpiego, India
43 Deepti Singh Jhpiego, India
44 Somesh Kumar Jhpiego, India
45 Vikas Yadav Jhpiego, India
46 Sudharsanam Jhpiego, India
47 Prasad Bogam Jhpiego, India
48 Sunita Dhamija Jhpiego, India
49 Mariam Luyiga Program for Accessible Health Communication and Education (PACE),Uganda