One of the major functions of the World Health Organization (WHO) is the preparation and promotion of clinical practice guidelines and health policy recommendations, with the aim of improving healthcare globally. WHO is often considered the ultimate authority when it comes to healthcare issues (1).

WHO does not apply its own guidelines

Unfortunately, WHO falls short of its reputation. For example, WHO guidelines on arterial hypertension had to be revised after being harshly criticised on the basis of sound arguments (2). Similarly, in the face of criticism, WHO had to revise the entire procedure by which it updates its essential drugs list, in order to make its methodology more rigorous and transparent (3,4). These weaknesses are not isolated exceptions in what is otherwise a globally reliable system: on the contrary, an in-depth survey shows that most guidelines issued by WHO do not meet contemporary quality criteria for the development of treatment guidelines (5).

An in-depth survey
A team of specialists in the quality of healthcare guidelines examined whether WHO applied good practice guidelines, currently considered essential, when preparing its recommendations, especially in terms of the transparency of the methods used, and the use of systematic reviews of available data weighed by the level of evidence. Officially, WHO adopted this approach in 2003 (6).

Between September 2003 and February 2004 the authors of the survey interviewed 21 directors (or deputy directors) of 16 WHO departments that produce guidelines, and conducted a detailed analysis of four reports containing important WHO therapeutic guidelines, on antiretroviral drugs, tuberculosis, malaria and children's health (5).

The results are shocking. At the time the interviews were conducted, almost none of the directors had applied (or even intended to apply) WHO's own rules, and some saw no reason for doing so. They appeared to ignore the concept of evidence-based medicine. Instead they relied on expert opinion, which is known to be unreliable because of lack of transparency in the selection of experts, weakness in the rationale provided for recommendations, and potential conflicts of interest (involving corporate pressure groups or private interests) (a)(5). All this seriously undermines WHO's reputation and questions the reliability of its publications. WHO has officially recognized these mistakes and has promised to do better in future (1).

Potential bias and outside influences
There are many advantages to the use of systematic reviews to produce clinical guidelines: in particular, this approach reduces the likelihood of guidelines being affected by various types of methodological bias. Other teams can also reproduce and verify guideline development (5). The risk of bias due to experts’ conflicts of interest is also limited (7).

Some WHO department directors said they were aware of flaws in their guidelines, citing a lack of resources and time. However, the authors of the survey concluded that WHO could make better use of existing resources by adopting proper working methods. They also highlighted the fact that this United Nations organisation is heavily reliant on external funding, over and above Member States’ required contributions (5).

This WHO dependence on external funding, sometimes from private sources, has increased in recent years and amounted to 72.4% in 2006-2007 (8). Some WHO activities unfortunately depend almost exclusively on external funding (b). Worse yet, WHO allows staff members to be paid directly by external sponsors such as drug companies (9,10).

One pet project of recent WHO directors has been to promote public-private partnerships in an attempt to help solve global health problems. Yet this simply aggravates the consequences of not using systematic and transparent procedures to develop recommendations. Restoring WHO credibility. As WHO directors are now promising, it is time for the Organization to strengthen its credibility in the field of practice guidelines, especially as poor countries often depend on them (1). This will require the implementation of good guidelines for practice in the development of recommendations. It will also mean reducing WHO’s financial dependence on the private sector, and increasing Member State contributions so that future recommendations are independent of outside influences. Also, all outside experts employed by WHO must declare conflicts of interest.

This survey again reminds healthcare professionals and decision-makers of the dangers of modifying their practices solely on the basis of claims of opinion leaders or other expert advice. It also highlights the fact that a guideline programme can only be credible when it uses explicit, transparent and systematic working procedures (11).

We hope the results of this survey will serve as encouragement to all WHO personnel who are seeking to ensure that their organization fulfills its global health mission.

©Prescrire 2007

Prescrire Int 2007; 16 (92): 259.

Notes:
a- The exclusive use of experts is ironically referred to as the "GOBSAT" method ("good old boys sat around a table") (ref. 7).
b- For example, the document entitled "Mental Health Policy and Service Guidance Package- Child and Adolescent Mental Health Policies and Plans" was written with “the generous financial support of the governments of Australia, Italy, New Zealand and the Netherlands and of the Eli Lilly & Co Foundation, and Johnson and Johnson Social Corporate Responsibility, Europe” (ref 12). See also ref. 13.

References:
1- Hill S and Pang T "Leading by example: a culture change at WHO" Lancet 2007; 369: 1842-1844.
2- Prescrire Editorial Staff "Flawed WHO recommendations on hypertension" Prescrire Int 1999; 8 (142): 121-123.
3- Prescrire Editorial Staff "OMS: des médicaments essentiels, sauf pour les pauvres" Rev Prescrire 2001; 21 (215): 221.
4- Prescrire Editorial Staff “Médicaments essentiels: l’OMS redresse le cap” Rev Prescrire 2003; 23 (239): 381-382.
5- Oxman AD et al. "Use of evidence in WHO recommendations" Lancet 2007: 369: 1883-1889.
6- "Guidelines for WHO guidelines" WHO 2003. Website whqlibdoc.who.int/ hq/2003/EIP_GPE_EQC_2003_1.pdf  accessed 15 June 2007: 24 pages.
7- Nathwani D "From evidence-based guideline methodology to quality of care standards" J Antimicrob Chemother 2003; 51: 1103-1107.
8- "Proposed programme budget 2006-2007 - notes on revisions to the proposed programme budget 2006-2007 since the 115th session of the executive board". Website www.who.int accessed 16 May 2007: 14 pages.
9- Correspondence between Health Action International and WHO in 1999. Website www.haiweb.org accessed 16 May 2007: 4 pages.
10- "Guidelines on working with the private sector to achieve health outcomes" Report of the Executive board, 107th Session, 30 November 2000. Website www.who.int accessed 29 June 2007.
11- Prescrire Rédaction "Guides de pratique clinique: faire le tri, et savoir jeter" Rev Prescrire 2007; 27 (282): 304-306.
12- World Health Organization "Mental Health Policy and Service Guidance Package-Child and Adolescent Mental Health Policies and Plans". Website www.who.int accessed 15 June 2007.
13- Prescrire Editorial Staff "Conflicts of interest. WHO performance under scrutiny" ISDB Newsletter 2007; 21 (1): 17-20.