| In a few short years, clinical guidelines have gained an aura of respectability and infallibility that took such medical breakthroughs as germ theory and vaccination generations to attain. In industrialized countries, the combined impetus of medical research, financial accountability, and the evidence-based movement has set guidelines on a pedestal above many other medical tools, but one that is constantly examined for weaknesses. Developing countries, in contrast, have begun to adopt guidelines, but little is known about their effectiveness in health systems characterized by scant resources and rigid bureaucracy. This dissertation explores the effectiveness of a particular type of guidelines, those for family planning service delivery, when they are introduced in the developing world.; The first chapter critically reviews the large literature for keys to the success or failure of guidelines. We examine what has worked, and why, in industrialized countries, and we draw conclusions about how guidelines might best be developed and disseminated in a developing country context. Specifically, we interpret the guidelines literature in the light of three important differences between developing and industrialized countries: (1) resource availability, (2) organization of services, and (3) target audiences.; In the second chapter, we narrow our focus to family planning service delivery guidelines in developing countries, and explore the notion that evaluation of these guidelines can benefit from two types of routine data collection. At the macro level, periodic, donor-financed surveys called situation analyses may be an ideal mechanism to measure adherence to guidelines. At the micro level, family planning providers, who routinely record many details of their client interactions, may have shelves full of useful data.; Chapter Three puts the lessons of the first two papers into practice to answer the question "Did Family Planning Service Delivery Guidelines Improve Provider Practices in Senegal 1994--1998?" In contrast to evaluators of European and North American guidelines who content themselves with a single indicator of compliance, we explore the relatively uncharted path of evaluating guideline compliance with both an indicator score and a score of indicators. The results are both understandable, in light of Chapter One, and conclusive, in light of Chapter Two. |
