Availability of Standard Operating Guidelines for Primary Healthcare Facilities in Sub-saharan Africa: A Scoping Review Protocol

Background: Primary healthcare (PHC) clinics play an essential role in the delivery of community-based health services, particularly in resource-limited settings. However, there is little systematic documentation on the availability of standard operating guidelines governing their operation or evaluating the services provided by PHC facilities. This study, therefore, will aim to systematically map literature and describe the evidence on the availability of standard operating guidelines or procedures for PHC facilities in sub-Saharan Africa (SSA). Methods: This scoping review study will be conducted inline with the Arksey and O'Malley's framework. PubMed, EBSCOhost (Academic search complete, CINAHL with full text, and Health Sources), Scopus, and Google Scholar will be searched from 2010 to 2020 for relevant evidence sources using a search strategy comprising of keywords, Boolean terms, and medical subject headings. This study will include evidence sources/studies written/published in English that focused standard on standard operating guidelines for stang and operational management, patient care and service provision, and quality monitoring procedures to assess the functioning of PHC facilities in SSA. The screening of the evidence sources/studies at all the stages and the data extraction will be conducted independently by two reviewers. Thematic analysis will be carried out to identify the themes and sub-themes and the ndings relating to this study's research question summarised and reported for each theme narratively. Discussion: This scoping review anticipates to highlight standard operating guidelines available for stang and operational management, patient care and service provision, and quality monitoring procedures to assess the functioning of PHC facilities to inform the development of relevant standard operating guidelines to improve healthcare services at the primary level. This study also anticipates revealing literature gaps for future research to ensure the attainment of universal health coverage by 2030.

monitoring procedures to assess the functioning of PHC facilities in SSA. The screening of the evidence sources/studies at all the stages and the data extraction will be conducted independently by two reviewers. Thematic analysis will be carried out to identify the themes and sub-themes and the ndings relating to this study's research question summarised and reported for each theme narratively.
Discussion: This scoping review anticipates to highlight standard operating guidelines available for sta ng and operational management, patient care and service provision, and quality monitoring procedures to assess the functioning of PHC facilities to inform the development of relevant standard operating guidelines to improve healthcare services at the primary level. This study also anticipates revealing literature gaps for future research to ensure the attainment of universal health coverage by 2030.

Background
An essential component to achieve the United Nations sustainable development goals is the implementation of universal health coverage (UHC). However, ensuring the availability and accessibility of healthcare to all in Sub-Saharan Africa (SSA) like elsewhere in the world remains challenging [1,2]. Despite the African region being burdened by about 24% of the global burden of disease [2,3], it is severely challenged to ensure equitable health care services at the community level. This challenge is a result of a frail health system (weak governance), lack of human resources, limited nancial resources, unreliable supply chains, and increasing populations, high burden of communicable and noncommunicable diseases coupled with poorly developed health infrastructure in several SSA countries [3,4].
A 2017 report by the World Bank indicates that at least half the world's population still lacks access to essential health services [5]. With reference to UHC services, the report identi ed SSA as having the lowest coverage index value (42) compared to Southern Asia (53), East Asia (77) and Northern America and Europe (77) [5]. Community-based health services have been implemented to address the shortage and to improve healthcare coverage [2]. Community-based health services may comprise of preventive, promotive, curative services, and rehabilitation depending on the country's disease burden, the gap in service coverage, and the availability of funding [2]. The competencies of Community health workers vary greatly, and they deliver services related to sexual and reproductive health, tuberculosis, human immunode ciency virus, disease surveillance and contact tracing, mental healthcare, and others to individuals, families, and communities [2,6].
Community-based services such as those offered in clinics and health centres enhance equitable access to healthcare at the primary level [8]. Such services play a vital role to prevent the spread of disease, and effective and prompt treatment can provide holistic care. It is therefore essential that community-based primary healthcare (PHC) systems be strengthened [7]; especially in resource-limited settings where people face numerous challenges. The challenges include inadequate health infrastructure, insu cient sta ng with high attrition, low referral systems, lack of standardised practice, poor planning for medication and medical supplies and inadequate supervision [8,9].
The success and sustainability of community-based health services thus rest on the uniform application of standard guidelines and adherence to operational procedures. Whilst there are abundant publications on the elements of community-based work and types of services being provided, there is little systematic documentation on the availability and use of standard operational guidelines to evaluate the services provided by community-based health facilities. This scoping review aims to systematically map literature and describe the evidence on the availability of standard operating guidelines or procedures for PHC facilities in SSA focusing on standard operating guidelines for sta ng and operational management, patient care and service provision, and quality monitoring procedures to assess the functioning of PHC facilities in SSA. Findings from this study will help to address governance challenges at the PHC level, improve community-based healthcare services towards the attainment of UHC, and it will help to identify gaps for future research in SSA.

Methods
This study will be a scoping review. Findings will enable us to search and select literature systematically, and synthesised the available evidence on the standard operational guidelines/policies for communitybased health facilities in SSA [10,11]. Aside from this, the scoping review method will enable us to map the concepts and describe the range of evidence available and identify research gaps [10,11]. This scoping review will be guided by an adapted Arksey and O'Malley framework [10,12]. The framework comprised of the following: identifying the review question; identifying relevant evidence sources/studies; study selection; charting the data; and collating, summarising and reporting the results. To aid the development of this study protocol, we adopted the preferred reporting items for systematic review and meta-analysis for protocols (PRISMA-P), but the resulting paper will be reported in line with the PRISMA extension for a scoping review checklist [13].

Identifying the research question
The main research question this scoping review will seek to address is: To date, what evidence exists on the availability of standard operating guidelines or procedures for PHC facilities in SSA?. The sub-review questions are as follows: 1. What standard operating guidelines exist for sta ng and operational management of PHC clinics in SSA?
2. What standard operating guidelines exist for patient care and service provision at PHC clinics in SSA?
3. What standard operating guidelines exist for quality monitoring procedures to assess the functioning of PHC facilities in SSA?
Identifying relevant evidence sources Searches will be conducted on PubMed, EBSCOhost (Academic search complete, CINAHL with full text, and Health Sources), Scopus, and Google Scholar from 2010 to 2020 for relevant evidence sources to answer the review question. The search will employ keywords, Boolean terms ("AND" and "OR"), and medical subject headings to develop a comprehensive search strategy ( Table 1). The syntax will be modi ed where needed. The team will also use the services of an experienced subject librarian to ensure that a robust review search strategy is followed. The PCC framework helped to specify the scope of the relevant publications.
Limitations on study design will be removed, but language limitations will be included where possible during the search. The search records will be documented appropriately. That is search date, database, keywords, search results, and count of eligible articles. To guide the electronic search strategy, the PRESS (Peer Review of Electronic Search Strategies) statement will be used [14]. The reference list of the included sources of evidence, Google, and the WHO website will also be consulted for evidence relating to standard operating guidelines for PHC level facilities in SSA. To compile all relevant evidence sources, identify and remove duplicate records, we will use the EndNote X9 reference manager. NS will search for the evidence sources assisted by the review team and import them onto an EndNote library created for this review.   Selection of evidence source Following the compilation of all evidence sources, the EndNote library will be cleaned by deleting all duplicate records. All tools or forms that will be used for the selection of the evidence sources will be piloted tested, and the needed amendments made to ensure their accuracy and reliability. Subsequently, the EndNote library will be shared among the review team. To reduce selection bias, two reviewers (NS and JvW) will conduct the title and abstract, and the full-text article screening independently. Guided by this scoping review eligibility criteria, the evidence sources will be sorted into either "include" or "exclude" group. At the abstract stage, discrepancies that may arise between NS and JvW will be discussed by the review team until a consensus is reached. A third reviewer will independently address any discrepancies that ensue between NS and JvW at the full text screening stage. We will use the University of KwaZulu-Natal library services to retrieve all full-text articles with closed access publications. Emails will also be sent to the original authors to request relevant full-text articles if needed. The various stages of the evidence sources selection will be appropriately documented using an amended PRISMA ow diagram ( Figure 1) [15].
Charting the Data A spreadsheet will be developed for the data charting. The spreadsheet will be piloted independently by NS and DK using a minimum of ten percent of the included evidence sources to ensure consistency. The review team will resolve all discrepancies, and the needed amendments will be done before its nal usage to enable the capturing of all relevant data and reliability of this study results. The data will be extracted using both inductive and deductive approaches [16]. The following data will be collected: The data extracted will be analyzed using thematic content analysis approach (coding and categorisation) [16]. Relevant ndings for each of the themes or sub-themes will be summarised and reported narratively. Figures and tables where appropriate will be used to present the characteristics of the evidence sources.

Discussion
This scoping review study aims to systematically map literature and describe the evidence on the availability of standard operating guidelines/procedures for PHC facilities in SSA. The world has set out to attain universal health coverage by 2030, and the role of PHC clinics services is highly essential. To this end, systematic documentation on the availability of standard operating guidelines governing PHC clinic operations or use to evaluating the services provided by PHC facilities is much needed. Given this, this study will source the most recent literature published within the last ten years relating to standard operating guidelines/procedures for PHC facilities in SSA focusing on sta ng and operational management, patient care and service provision, and quality monitoring procedures to assess the functioning of PHC facilities. Due to lack of expertise in other o cial languages, this study will include only literature published in English. This study anticipates revealing evidence to inform the development of relevant standard operating guidelines to improve healthcare services at the primary level. This study also anticipates revealing literature gaps for future research to ensure the attainment of universal health coverage by 2030.  PRISMA 2009 Flow Diagram [15] Supplementary Files This is a list of supplementary les associated with this preprint. Click to download.