1. 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, January, 2010

2. 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

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

4. 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

5. 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?

6. 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

7. 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

8. 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

9. 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

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

11. 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