Table 1

A summary of the evolution of the strategy for developing evidence-based clinical guidelines from 2005 to 2015

Year of activityTopic selection and number of topicsStakeholders involvedTechnical preparation and materials developedFormat and duration of discussionsGuideline panellistsDecision-making process and documentationOutputsPolicy changes and Outcomes
200514 topics selected based on morbidity and mortality of common inpatient conditions and identified areas of poor quality care in KenyaResearchers completed reviews and set up meeting; clinical community engaged in the first ‘Child Health Evidence Week’.Rapid, contextualised systematic reviews prepared, and presented at the meeting;
reviews not provided to panel in advance
A local expert selected by researchers was given the systematic review and slides before the meeting and asked to present the evidence; presentation of evidence and discussion lasted about 1.5 hours per topic.35 participants: mostly university paediatricians, some Medical Training College faculty (who trained non-physician clinicians), local researchers and MoH personnelNo formal consensus process; chair highlighted the evidence, existing WHO recommendation and potential adaptations, and facilitated agreement (assent);
recommendation documented, but not the discussion
Four systematic reviews were published in peer-reviewed journals.First national paediatric and neonatal guidelines for hospital care spanning major conditions; previously only available for malaria and HIV;
although approved by the MoH in 2006, they were produced in small numbers until 2008 when 10 000 distributed
20102005 edition update: 11 topics focused on important new research in existing topics covered, and by requests of those teaching use of the guidelinesThe researchers completed reviews but engaged with the MoH, the  KPA and the UoN in coordinating the reviews and meetingRapid reviews produced with MoH or UoN staff jointly after GRADE training;
reviews and SoF provided at the start of the meeting; participants were sent reviews for 3 key topics 4 weeks prior to the meeting as part of a trial14
Panel induction on GRADE (2 hours); evidence presentation and discussion 1.5 hours followed by a 2-hour facilitated discussion on recommendations; voting using a modified GRADE grid helped generate recommendations60 participants: mostly paediatricians from two major medical schools, Medical Training College faculty, pharmacists with procurement roles, MoH personnel and local WHO officersNon-voting facilitator guided discussions, the group examined the evidence before draft recommendations were discussed, taking account of context, feasibility, and preferences; blinded vote on draft recommendations with results reviewed 1 day later in 30 min to make final recommendationsUpdated 2005 Guidelines;
five reviews published in peer-reviewed journals and all reviews made available on a website;
formal evaluation of the process published14 15
11 policies revised;
12 000 copies of updated guidelines disseminated with the MoH;
in-service, undergraduate and postgraduate training were updated to reflect changes
2013Three topics selected: two where major trials published (intravenous fluids in shock, cord care), and one for a drug entering practice without evaluation of benefits/harms (hydroxyurea in sickle cell disease)The research team, the MoH and the KPA organised for three specific reviews to inform three topic-specific guideline panels each to convene at the annual national paediatric conferenceResearchers and seconded members of the MoH and UoN completed reviews with SoF tables; support from the Cochrane Infectious Diseases group;
reviews were sent 4 weeks in advance of the panel meeting with electronic copies of original references
Panel induction on GRADE (2 hours) before each panel started work; panels chaired by one non-expert member; evidence presented by review author and discussed, panel decided level of certainty of effects (1.5–2 hours), followed by discussions informed by the DECIDE framework on risks and benefits, feasibility and acceptability of possible recommendations (4–8 hours); facilitation by a senior researcher and technical experts not involved in final decisionsSpecific panels selected for each topic (3 in 2013 and 4 in 2015) each with 16–20 panellists; core personnel from the MoH, representatives of regulatory and training bodies for clinical officers and nurses, and the national medicines procurement body (also representing pharmacists) sat on all three panels; they were joined by 8–10 additional panel-specific members drawn from among topic-specific experts, and medical and nursing practitioners from typical district hospitalsMeetings were preceded by disclosure of interests;
chairperson and facilitator sought to foster participation, full exchange of views and then develop consensus; the participation, process, key discussion points and recommendations were documented in a guideline panel report that named all participants and reported their roles
Reports and draft recommendations made publicly available on a website and given to the MoH to make final decision on recommendations;
revised national guidelines produced after MoH finalised recommendations
2013: Evidence, discussions and draft recommendations immediately disseminated at conference
2013: Three reviews published in peer reviewed journals
2015: MoH held multistakeholder donor meeting to promote and get support for new pneumonia policy
Revised guidelines including three new recommendations were published and 12 000 copies distributed before the end of 2013;
neighbouring countries used evidence materials and amended guidelines
2015Pneumonia trial initiated given insufficient evidence in 2010; on completion a guideline panel was constituted; two neonatal care topics not reviewed since 2005, one topic concerned guidance on a technology (CPAP) being introduced in an ad hoc fashion by hospitalsAs in 2013 the research team worked with the MoH, the KPA and the UoN; 6 paediatricians joined researchers to form systematic review teams 6 months in advance of the planned guideline meetingsFour systematic reviews spanning guideline-related questions; reviews done by emerging junior team supported by an experienced Kenyan researcher and one by international collaborators; all reviews had GRADE SoF tables; these were sent out to panellists 4 weeks before panel meetingsRevised protocols including four new recommendations were published and 12 000 copies distributed in 2016
  • CPAP, continuous positive airway pressure; MoH, Ministry of Health, Kenya Paediatric Association (KPA), University of Nairobi (UoN), Grading of Recommendations, Assessment, Development and Evaluation (GRADE), Summary of Findings (SoF)