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Improving the quality of WHO guidelines over the last decade: progress and challenges

The World Health Organisation’s (WHO) guidelines range from specific interventions targeting emerging health issues to general public health guidance. In 2007, WHO established the Guidelines Review Committee (GRC) to ensure that WHO guidelines meet the highest international standards and contain trustworthy and implementable recommendations. While the GRC played a positive role in the quality control of guidelines, these were often too long and technical, dissemination needed to improve and more products were needed for targeted audiences among other concerns such as issuing recommendations despite low-quality evidence,

A recent WHO evaluation concluded that although the GRC played a positive role in quality control of guidelines, the guidelines were often too long and technical, distribution needed to improve, and more derivative products are needed for specific audiences. Other identified concerns include issuance of strong recommendations despite low-quality evidence, suboptimal use of evidence in developing recommendations, insufficient diversity among guideline development group members, and incomplete adherence to WHO’s conflict of interest policy.

The production of high-quality guidelines is challenging for any organisation. WHO faces additional challenges having to adapt global recommendations to a local setting, which requires derivative products such as implementation tools or how-to manuals to ensure uptake. WHO Collaborating Centres, of which there are over 700 globally, play a crucial role in supporting guideline development; however, confusion arises when Collaborating Centres publish advice that is interpreted as being issued by WHO when this is not the case. Development of guidelines for emergency settings is particularly challenging because of time constraints and the evidence to inform future actions is often insufficient, particularly in the context of evolving or emerging public health threats. Finally, the framework underpinning guideline development at WHO—the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)—was initially developed for clinical interventions, and although GRADE can be successfully applied to the development of guidelines in public health, there are numerous challenges, such as the formulation of recommendations on complex interventions, use of non-traditional types of data (eg, big data), and hazard identification.

Several steps would improve the quality of guidelines issued by WHO. First, WHO needs to put the necessary resources, both monetary and staff time, into producing trustworthy and effective guidelines. Second, WHO needs to promote and support evaluations of its guidelines to ensure an ongoing cycle of quality improvement. Third, collaboration needs to be augmented both within WHO and with external partners so that common challenges are discussed and solutions shared. Fourth, clear processes and methods for guideline development in the context of emergencies are needed to help to ensure valid recommendations and optimal transparency and usability, regardless of the development timeframe. Finally, guideline development must be receptive to the needs of end users. Guidelines need to be succinct and written for the target audience, while still describing transparent methods. Tools for guideline implementation, adaptation, and updating need to be planned from the beginning of each guideline development process, and not treated as afterthoughts.

WHO looks forward to its next 10 years of guideline development, meeting the substantial challenges head on, while continuing to self-reflect, evaluate, learn, and evolve. In an increasingly crowded arena of global health, WHO will work to ensure that its guidelines remain a trustworthy source of relevant, usable, and impactful normative guidance for Member States and the global public health community.

[Source: The Lancet]