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  1. 1
    Peer Reviewed

    A number of factors explain why WHO guideline developers make strong recommendations inconsistent with GRADE guidance.

    Alexander PE; Gionfriddo MR; Li SA; Bero L; Stoltzfus RJ; Neumann I; Brito JP; Djulbegovic B; Montori VM; Norris SL; Schunemann HJ; Thabane L; Guyatt GH

    Journal of Clinical Epidemiology. 2016; 70:111-122.

    Objective: Many strong recommendations issued by the World Health Organization (WHO) are based on low- or very low-quality (low certainty) evidence (discordant recommendations). Many such discordant recommendations are inconsistent with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance. We sought to understand why WHO makes discordant recommendations inconsistent with GRADE guidance. Study Design and Setting: We interviewed panel members involved in guidelines approved by WHO (2007e2012) that included discordant recommendations. Interviews, recorded and transcribed, focused on use of GRADE including the reasoning underlying, and factors contributing to, discordant recommendations. Results: Four themes emerged: strengths of GRADE, challenges and barriers to GRADE, strategies to improve GRADE application, and explanations for discordant recommendations. Reasons for discordant recommendations included skepticism about the value of making conditional recommendations; political considerations; high certainty in benefits (sometimes warranted, sometimes not) despite assessing evidence as low certainty; and concerns that conditional recommendations will be ignored. Conclusion: WHO panelists make discordant recommendations inconsistent with GRADE guidance for reasons that include limitations in their understanding of GRADE. Ensuring optimal application of GRADE at WHO and elsewhere likely requires selecting panelists who have a commitment to GRADE principles, additional training of panelists, and formal processes to maximize adherence to GRADE principles. Copyright: 2016 Elsevier Inc.
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  2. 2
    Peer Reviewed

    What's in a name? Policy transfer in Mozambique: DOTS for tuberculosis and syndromic management for sexually transmitted infections.

    Cliff J; Walt G; Nhatave I

    Journal of Public Health Policy. 2004; 25(1):38-55.

    In this paper we set out to explore the common assumption that international health policies are imposed on developing countries, owing to their high level of dependence on international aid. We examine how far two globally promoted infectious disease policies - directly observed short course therapy (DOTS) for tuberculosis (TB) and syndromic management for sexually transmitted infections (STIs) were voluntarily or coercively transferred in one particular setting, Mozambique. The findings of this case study are part of a larger study, which looked at global policy making, and compared South Africa and Mozambique. The larger study used the analytical frameworks developed to study policy transfer between jurisdictions. It showed that both policies had evolved in the 1980s through technical networks of national and international experts, and that policy transfer was not a linear, top-down process, but occurred in a series of policy loops over a long period. Experience at the country level fed into the globally promoted policies of the 1990s as part of this ‘looped process.’ The results of the global level research are being reported for policy theorists in a separate article. In this paper, we aim to present the findings of our case study of the transfer process and implementation of the policies in Mozambique and draw appropriate lessons for public health professionals working at the national level. (excerpt)
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  3. 3
    Peer Reviewed

    Scaling-up treatment for HIV / AIDS: lessons learned from multidrug-resistant tuberculosis.

    Gupta R; Irwin A; Raviglione MC; Kim JY

    Lancet. 2004 Jan 24; 363(9405):320-324.

    The UN has launched an initiative to place 3 million people in developing countries on antiretroviral AIDS treatment by end 2005 (the 3 by 5 target). Lessons for HIV/AIDS treatment scale-up emerge from recent experience with multi-drug-resistant tuberculosis. Expansion of treatment for multi-drug-resistant tuberculosis through the multi-partner mechanism known as the Green Light Committee (GLC) has enabled gains in areas relevant to 3 by 5, including policy development, drug procurement, rational use of drugs, and the strengthening of health systems. The successes of the GLC and the obstacles it has encountered provide insights for building sustainable HIV/AIDS treatment programmes. (excerpt)
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