The injustice of unfit clinical practice guidelines in low-resource realities

28 March, 2021

On HIFA we have long recognised the importance of country-level adaptation of WHO and other global guidelines. We have noted that many countries face challenges to adapt and apply such guidance. This Viewpoint paper affirms that the information needs of health workers in low-resource settings are not being met, and current non-realistic guidance may, paradoxically, be contributing to unintentional harm in clinical practice. 'Development and adaptation of high-quality, contextualised, realistic CPGs will assist health providers in saving lives rather than causing immobility by a desire for perfection.'

This paper is very relevant to HIFA and I invite your comments. I have invited the authors to join us.

CITATION: The injustice of unfit clinical practice guidelines in low-resource realities

Nanna Maaløe et al. Lancet Global Health

Open Access Published:March 22, 2021



To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle-income countries through co-creation with end-users, and we encourage global sharing of these experiences.


“The women are in pain, some look frightened and many are calling for my attention. It is a typical night duty in the maternity ward. Eighteen women are admitted in the congested labour room, two in each bed. A young nurse and I are the only staff in the room. I see a head crowning in bed four and an oxytocin drip next to bed two running too fast. The nurse reports that one of the women with severe preeclampsia is fitting. It is a long time since any woman had assessments of foetal heart rates, and their unborn babies may have been crying out for help in silence. I am quickly casting a glance on the room's wallpaper of guidelines. They all are there, from the Ministry of Health to international aid organizations. Fading instructions and illustrations depict the what-if scenarios if only I had one woman with one illness at a time. I force my gaze back at reality and feel alone” (reconstruction of lived experiences of health professionals in Tanzanian maternity units, unpublished data).


Fundamental gaps between international recommendations and realistic best practice continue to be reported in low-resource settings, and evaluation of the implementation and effectiveness of CPGs is largely neglected...

In this Viewpoint, we address this underexposed yet long-standing injustice of leaving health providers without useful guidance. We suggest ways forward, and we call for action, at global and local levels, to develop contextualised, realistic CPGs for health providers practising where guidance is most acutely needed.

Multilateral health agencies appear to take for granted that their CPGs will be adequately adapted to local contexts regionally, nationally, or subnationally. However, it is generally acknowledged that few LMICs are equipped with the necessary human, technical, and financial resources to carry out such adaptations, including time, access to evidence, knowledge and training on synthesising and applying evidence, and coordination of the different stakeholders. Therefore, international recommendations are typically endorsed nationally after varying degrees of suboptimal adaptation by a panel of experts, or even (inappropriately) directly adopted.

Front-line health providers are... asked to use CPGs that are dangerously incomplete, irrelevant, impractical, or outdated.

Astonishingly, augmentation of the technical bar for evidence synthesis in CPG development, which has occurred over the past two decades, has not been matched by a strengthened focus on pilot testing and postimplementation evaluation. This finding stands in contrast to CPG research in HICs...

Development and adaptation of high-quality, contextualised, realistic CPGs will assist health providers in saving lives rather than causing immobility by a desire for perfection.


Best wishes, Neil

Coordinator, HIFA Project on Evidence-Informed Policy and Practice

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health movement (Healthcare Information For All - ), a global community with more than 20,000 members in 180 countries, interacting on six global forums in four languages in collaboration with WHO. Twitter: @hifa_org FB: