A Guide to Developing and Testing a National Self-Care Policy

In 2020, Uganda began the process of developing a national self-care guideline for sexual and reproductive health and rights, based on the World Health Organization (WHO)’s guideline on self-care, released in June 2019 and revised in 2022. The WHO guideline provides a people-centered, evidence-based framework, along with normative guidance, to support individuals, communities, and countries to put in place high-quality health services and self-care interventions.

Uganda’s goal was to carry on these principles while ensuring that the national policy was well adapted to Uganda’s health system and cultural context. Typically, when a country creates a national policy based on international guidelines, the policy is approved and instated without testing, providing an opportunity to better understand how the health system will react to the policy, learn from these experiences, and modify the policy as needed. In this case, Uganda chose a “sandboxing” approach, which included developing, testing, and modifying the policy before approving and implementing it.

How-to for Other Countries

Acknowledging the gap in documentation of approaches to health policy development, Samasha partnered with USAID’s PROPEL Health project to create a how-to guide based on Uganda’s self-care policy development process, titled “Localizing WHO Guidelines on Self-Care: A Practical Guide From Uganda.” Available in English and French, the guide documents Uganda’s innovative approach and illuminates a guideline development process that may be helpful for other countries.

The resource is organized by the five phases of the process undertaken by Uganda, detailing the purpose and objectives of each phase, Uganda’s experience, lessons learned, and suggested activities and tool for other countries wishing to follow a similar process to develop national self-care guidelines. The lessons learned were developed to be relevant to other countries working towards a national self-care guideline and relate to both the policy creation and testing process and the self-care interventions themselves.

The Government of Liberia is currently using this how-to guide to replicate the Uganda approach, with the expected result of national self-care guidelines adapted to the Liberia context.

Uganda’s Five-Phase Approach

Uganda’s five-phase approach to developing, testing, and implementing self-care guidelines can help to ensure that a country’s self-care guidelines are supported by national and district leadership; fit within the existing health system; and are acceptable and appropriate to health workers, self-carers, and other stakeholders.

1. Government Ownership

As in the development of all new government policies and programs, in the first stage of developing national self-care guidelines, cultivating the support of national leadership and coalescing civil society and development partners around a common agenda are essential.

Key lessons from Uganda’s experience to inform this phase include having a strong justification for creating self-care guidelines specific to the context and fostering government ownership or involvement from the beginning through regular briefings and sharing successes from other countries.

2. Establish a Self-Care Expert Group

The adaptation process began with the establishment of a Self-Care Expert Group chaired by the Ministry of Health’s Director of Clinical Health Services, with support from the Assistant Commissioner for Adolescent and School Health. A consultant from Samasha Medical Foundation executed the guideline development process, facilitated meetings, and ensured all tasks stayed on course.

Ensuring diverse expertise across multiple health areas and cross-cutting issues in this group was important to Uganda’s success. Since no such group existed in the country, a new group was established.

3. Conduct a Situational Analysis and Develop Draft Guidelines

It is important to have a complete understanding of how the guidelines will fit into the existing health care system and policies, what self-care options are currently available, and what the experience has been with self-care in the country. Situational analyses were conducted by the self-care consultant and by the expert group members. The drafted guidelines were strongly rooted in the findings from this analysis.

The Uganda team found it helpful to host a two-day meeting among the expert group to determine the purpose, objectives, guiding principles, and priority interventions, which informed the development of the guidelines.

4. Sandbox the guidelines in a Learning District

“Sandboxing” refers to piloting or testing reforms or innovations under actual conditions in a defined space within a defined time period. After developing the draft guideline, the Self-Care Expert Group made the strategic decision to pilot test the draft guideline at the subnational level and use the lessons learned to inform revisions before national launch and scale-up. To pilot the guidelines in a real-life setting, the expert group used the sandboxing approach in Mukono District, located in Uganda’s Central region.

Sandboxing the guidelines can make a big difference in ensuring that you have the most effective policy for your setting, but it is resource intensive. To make sure that you make the most of your resources, focus on reaching clients who already visit health facilities because these will be the easiest to reach individuals for testing the acceptability of interventions. Social and behavior change is a critical element of successful self-care. The team in Uganda also found it cost-effective to use the existing health facility triage and planned health education talks on antenatal care, immunization, and other topics.

5. Revise and Finalize the Guidelines

Before final approval of the guidelines, the Self-Care Expert Group incorporated lessons learned from the sandboxing activity into the guidelines text. The guidelines then received additional approval from relevant government agencies before being implemented nationwide.

Some of the lessons learned from the sandbox include the need to use education and social and behavior change to combat provider resistance against self-care. Some resistance came from clinicians concerned about the quality of care that clients can receive without direct provider contact. Other resistance came from the owners of private facilities who were concerned about reduction in profits. Addressing misinformation about self-care processes and outcomes went a long way toward assuaging concerns.