Improving the quality of WHO guidelines over the last decade: progress and challenges
Authors: Susan L Norris, Nathan Ford
Journal: The Lancet Global Health (2017)

WHO is a leading and respected source of normative guidance. With a particular focus on the needs of low-income and middle-income countries, the scope of WHO guidelines is vast, ranging from specific interventions aimed at controlling particular aspects of emerging health threats (eg, Infant feeding in areas of Zika virus transmission1WHOInfant feeding in areas of Zika virus transmission. World Health Organization, Geneva2016Google Scholar) to broad public health guidance (eg, International travel and health2WHOInternational travel and health: situation as on 1 January 2012. World Health Organization, Geneva2012Google Scholar). WHO's guidelines have not been without controversy3Fineberg HV Pandemic Preparedness and response—lessons from the H1N1 influenza of 2009.N Engl J Med. 2014; 370: 1335-1342Crossref PubMed Scopus (353) Google Scholar, 4Kupferschmidt K High-profile cancer reviews trigger controversy.Science. 2016; 352: 1504-1505Crossref PubMed Scopus (3) Google Scholar, 5Owens B Storm brewing over WHO sugar proposal.Nature. 2014; 507: 150Crossref PubMed Scopus (7) Google Scholar and in response to substantial public criticism, WHO established the Guidelines Review Committee (GRC) in 2007 to ensure that WHO guidelines meet the highest international standards and contain trustworthy and implementable recommendations.6WHOWHO handbook for guideline development. 2nd edition. World Health Organization, Geneva2014Google Scholar Independent evaluations of WHO guidelines suggest that important advances have been made, notably in the use of systematic reviews to inform recommendations and efforts to identify and manage conflicts of interest.7Sinclair D Isba R Kredo T et al.World Health Organization guideline development: an evaluation.PLoS One. 2013; 8: e63715Crossref PubMed Scopus (44) Google Scholar Improvements were suggested, however, in stakeholder involvement, clarity of presentation, and attention to implementation issues.8Burda BU Chambers AR Johnson JC Appraisal of guidelines developed by the World Health Organization.Public Health. 2014; 128: 444-474Crossref PubMed Scopus (26) Google Scholar, 9Wang Z Norris SL Bero L Implementation plans included in World Health Organisation guidelines.Implement Sci. 2016; 11: 76Crossref PubMed Scopus (28) Google Scholar A recent WHO evaluation10Evaluation of the Impact Of WHO PublicationsCorporate evaluation commissioned by the WHO Evaluation Office [pre-publication version, October 2016]. TDV Global, Ottawa, Ontario2016Google Scholar concluded that although the GRC plays a positive role in quality control of guidelines, these guidelines are frequently too long and too technical, dissemination needs to improve, and more derivative products are needed for specific audiences. Other identified concerns include issuance of strong recommendations despite low-quality evidence,11Alexander PE Bero L Montori VM et al.World Health Organization recommendations are often strong based on low confidence in effect estimates.J Clin Epidemiol. 2014; 67: 629-634Summary Full Text Full Text PDF PubMed Scopus (52) Google Scholar suboptimal use of evidence in the formulation of 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, whose guidelines generally target all United Nations Member States, faces additional challenges. Global recommendations usually have to be adapted to the local setting, which requires derivative products such as implementation tools or how-to manuals to ensure uptake. WHO guidelines are generally disease specific, which might not reflect the way that national ministries of health are organised or care is delivered. Funding constraints might influence both priority setting (guidelines developed according to financial opportunities) and the quality of guidelines. 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.12Ford N Norris SL Hill SR Clarifying WHO's position on the FRAX® tool for fracture prediction.Bull World Health Organ. 2016; 94: 862-962Crossref PubMed Scopus (8) Google Scholar 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. The global guideline community has not reached consensus as to optimal methods for production of guidelines in such contexts. Finally, the framework underpinning guideline development at WHO—the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)13Guyatt GH Oxman AD Kunz R et al.Going from evidence to recommendations.BMJ. 2008; 336: 1049-1051Crossref PubMed Google Scholar—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. These include 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 augment its support for and use of evidence to inform normative guidance and public policy. 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. Evaluations need to examine production and oversight processes as well as the health effects of guidelines. 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. SLN and NF are salaried employees of WHO. They have no other financial interests to disclose. SLN is an active member of the GRADE Working Group, whose framework and methods for guideline development are used by WHO staff who develop guidelines.