Framework for clinical guideline development in resource-constrained settings Adapted from a presentation at the Rwanda First National Workshop on Noncommunicable Disease, held at Rwinkwavu District Hospital, Eastern Province, Rwanda, 18-19 January, 2010

Challenges High quality evidence comes from urban settings May not be relevant in low-income countries May not be relevant in rural settings Guideline development is expensive, time-consuming and requires clinical expertise Money, time and clinical expertise are in short supply in Rwanda

Key steps in guideline development Scope and purpose Stakeholder involvement Rigour of development Clarity and presentation Applicability

Scope and purpose Objectives What are the expected health benefits? Define the clinical questions to be addressed by guidelines Who is the target audience? Physicians, advanced nurses, basic nurses To whom does the guideline apply? Age range, sex, clinical condition, co-morbidity

Stakeholders Steering committee to reach consensus on stakeholders Policy leaders from the Ministry of Health Regional clinical leaders Rwandan Medical Association Rwandan Nursing Association Disease-specific Patient Associations Pharmacy task force Any others?

Rigor of Development Systematic literature review Criteria for selecting evidence clearly described Methods for formulating recommendations clearly described (voting or consensus techniques) Consideration of health benefits, side effects, risks, costs, resource allocation

Priority setting Priority groups: sick, young, poor? Cost of medications Can we obtain medications at a better price? Risk categories: Low risk groups – relatively smaller potential benefit, larger population High risk groups – relatively larger potential benefit, smaller population

Rigour of Development Explicit link between recommendations and supporting evidence External review prior to publication Clinical experts Methodology experts Piloting of guidelines in the target population Continual validation and adaptation Procedure for guideline updates

Clarity and Presentation Recommendations specific and unambiguous Different management options are clearly presented Key recommendations are easily identified Tools for applications are included K.I.S.S

Applicability Potential organizational barriers have been discussed. Potential cost implications have been considered. Key review process for monitoring and evaluation.

Summary: Key steps in guideline development Scope and purpose Define target population Stakeholder involvement Define the experts to involve in the process Rigour of development Pilot testing in target population Continual validation and adaptation Clarity and presentation K.I.S.S. Applicability Cost implications