Sylvia de Haan is Cochrane's Partnerships Co-ordinator, and blogs periodically about work with our partners. You can read more in her previous blogs about engagement with the WHO, as well our partnership with Wikipedia.
The World Health Organization (WHO) is Cochrane's largest external partner, and one of our oldest, with whom we have been in official relations since 2011. Cochrane’s 2017 Mid-Year Meeting in Geneva provided an excellent opportunity to also meet with the WHO. Two parallel training sessions, an introduction to systematic reviews and a session addressing advanced topics, were held in the morning of 3 April, and were attended by around 30 WHO staff members each. In the afternoon, more than 100 Cochrane delegates met with about 20 WHO staff to hear more about the ongoing work of the two partners, and to discuss strategies to further align Cochrane’s work to WHO’s needs.
Marie-Paule Kieny, Assistant Director General, Health Systems and Innovation, opened the meeting. She highlighted how evidence forms the foundation of the normative guidance WHO provides, and emphasized how WHO benefits from Cochrane’s research synthesis and methods expertise. She said that, to be credible as the world’s leading public health agency, WHO needs to further strengthen its in-house methods and systematic review expertise and to implement the principles of trustworthy guidelines in all parts of the Organization to provide Member States with valid and useful recommendations.
Following this opening speech, Lisa Bero, Co-Chair of the Cochrane Board, provided an overview of the current joint areas of work and the achievements to date. This includes links that have been created between WHO departments and Cochrane Groups, leading to joint priority setting work (for example by Cochrane Nutrition), sharing of expertise (for example Cochrane Global Ageing), and delivery of systematic reviews needed for guidelines. Cochrane has produced systematic reviews of relevance to global policy development for more than 20 years. In 2016, close to 90% of WHO guidelines used Cochrane Systematic Reviews. Cochrane Reviews also inform the reports of the WHO Expert Committee on the Selection and Use of Essential Medicines (177 reviews from 40 Cochrane Groups were used for the nine reports published between 2000 and 2015).
After these opening speeches, two examples of collaboration were shared, focusing on developing guidelines for health system questions, and on systematic reviews to inform complex interventions in nutrition (See the presentations by Glenton & Lewin, and Gülmezoglu and Macdonald & Peña-Rosas). Both these examples also highlighted some of the challenges in the collaboration, including the frequent mismatch between guideline and systematic review timeframes; and the lack of additional resources that are needed to complete reviews timely for the guideline development process.
In small group discussions, participants discussed these and other challenges in further detail and were prompted to suggest solutions that would support the further strengthening of the strategic partnership between Cochrane and WHO. The topics discussed ranged from standard and rapid guideline development, to facilitating use of qualitative and quantitative evidence, and ensuring applicability in low- and middle-income countries (LMICs). Clinical trials registration and collaboration on the International Clinical Trial Registry Platform (ICTRP) were discussed as well. Following is a summary of the suggestions made to further strengthen the relationship.
- Better align the WHO guideline and Cochrane review production processes to maximize time available to complete reviews. The WHO guideline development timeline can be challenging in terms of producing a full review from the start, often resulting in an update of an existing review only. Horizon scanning could be done by both sides to anticipate future topics, for example, by reviewing the guidelines published by WHO since 2007. These will be coming up for renewal at some point, and can provide insight in new and updated reviews that may be needed. Cochrane Review Groups can also be brought into the guideline process earlier. Furthermore, it would be useful to develop guidance for review teams working within a guideline context to facilitate the interaction, and for the WHO to publish its upcoming guidelines as soon as they begin planning.
- Create more linkages and relationships between WHO and Cochrane. There are already many connections between Cochrane Groups and WHO departments. But there are gaps. It would be useful to map WHO topic areas to Cochrane Groups, so that these gaps can be identified and relations developed. Other mechanisms to strengthen linkages are to work through Cochrane Fields (with their multiple connections to Cochrane Review Groups); or to encourage the use of Cochrane Engage to connect guideline developers with review authors. In general, dialogue and communication are essential to further build the relationship.
- Improve usability of Cochrane reviews. This can be done by engaging WHO in Cochrane priority setting activities, and by supporting Cochrane Groups in engaging WHO in their priority setting work. If Cochrane review topics are driven by global priorities then they can have higher impact. Collaborating in priority setting may also facilitate inclusion of research synthesis priorities from LMICs (WHO could provide input on the priorities of their Member States). Another key strategy to enhance usability is by considering important factors and outcomes in reviews, including patient-centred outcomes, based on evidence-based core outcome sets (for example building on the work of COMET and CROWN initiatives). Cochrane Groups can develop and insist on the use of core outcomes set for health conditions of public health importance. Currently, several outcomes used by Cochrane Review authors are not patient-centred and may therefore be less useful for guideline decision-making.
- Strengthen the commissioning process of reviews. Resourcing is often a challenge for the review authors and editorial bases of Cochrane Groups. WHO staff could be more closely involved in supporting review teams, for example by contributing staff as additional review authors. Having WHO priorities included in the Cochrane priority list will also make it more likely to receive support, including financial resources, within WHO. Financial support to review teams will help ensure that the review is ready in time for use by the guidelines developers. It also will ensure that Cochrane Reviews are published.
- Facilitate the conduct of rapid reviews in case of health emergencies. In health emergency situations, there is no time to wait for a full systematic review to be conducted. In such situations rapid reviews, or also the update of only part of a review (i.e. a single comparison, for example through a Targeted Update), may be sufficient and can replace the need for full reviews. Rapid reviews can also indicate the opportunity for a full systematic review to be conducted in future (i.e the example of Zika virus infection where rapid reviews identified good questions for future full reviews). Guidance is needed on when not to do a rapid review. This might be the case when the balance between benefits and harms is unclear or is expected to be marginal, or when reviews are needed on complex interventions. Cochrane could also consider appraising existing systematic reviews as a service to WHO. A challenge to Cochrane is how it can publish rapid reviews, as the current publishing platform does not accommodate them. Participants felt that this should be possible in future.
- Strengthen applicability of systematic reviews to LMICs contexts. Involving WHO in Cochrane priority setting processes is one way of bringing in more LMIC perspectives into Cochrane’s work. In addition, reviews with high relevance for LMICs could mention this specifically when discussing applicability of a review; Cochrane Review Groups could be encouraged to include more editorial representation from LMICs, and, in general, should have more communication with local Cochrane Groups based in LMICs so that they can learn about local priorities and contextual issues. More training workshops could be given in LMICs; experienced authors could be paired with less experienced authors; and more support could be provided for translation of review summaries to increase use. Another suggestion made was to provide access to the data that underlie guidelines, which will help adapt guidelines to national contexts.
- Facilitate the use of various types of evidence (quantitative and qualitative) in guideline development. Some thematic areas have few or no randomized controlled trials. Having methods to consider other types of evidence, in systematic reviews and guideline development, is essential. WHO and Cochrane can work together in exploring the challenges related to this and try out experimental reviews. Some of the challenges include:
- the difficulty to define what we want to know when looking at complex interventions in health systems;
- the different type of questions asked in a Cochrane Review (question related to a single intervention) versus a guideline (question related to a package of care);
- the skills and resources that author teams will need to have when dealing with these complex interventions; and
- the many reviews needed to address guidelines on complex interventions – with the related time challenge to keep these up to date.
There is a need to align Cochrane Review update priorities with the guideline development priorities. We should also consider the use of living systematic reviews to facilitate updating guideline recommendations. This would link to the WHO/RHR “Living guidelines project” – and could evolve into a closer and longer-term arrangement for updating of the evidence base for existing WHO recommendations.
- Collaborate on clinical trial reporting. WHO’s position on clinical trial registration is that all trials are prospectively registered and results disclosed. Production of Cochrane Reviews is dependent on trial reporting and searching trial registries is mandatory for Cochrane Reviews. Both organizations share interests and goals in regard to encouraging clinical trial registration and ensuring that trial registration data are freely and easily available. This commonality led the group to agree action points on improving prospective trial reporting, reducing the number of unregistered trials, and strengthening the collaboration between both organizations:
- WHO (through the ICTRP team) would take the lead on drafting an action plan to advance prospective registration and defining the standards for reporting of results. This action plan would be shared with Cochrane and other agencies. The aim is to present at the Global Evidence Summit in Cape Town and solicit further input and commitment.
- ICTRP faces technical challenges. The group proposed to solicit the views of reviewers (including Cochrane Groups) and trialists about how they think the data in ICTRP could be better structured.
- Cochrane to engage with a group of interested parties to draft a prioritized list of technical changes to ICTRP (portal & API).
- The Global Observatory on Health R&D aims to visualize retrospective trial registration. Further work is continuing and ICTRP would like to receive feedback from Cochrane on this.
Cochrane would like to see its relationship with WHO expand further. We would like to be more responsive to WHO’s needs in terms of relevant systematic reviews and in terms of provision of technical and methodological expertise. We would also like to increase our visibility and work with all major WHO departments as a trusted partner for evidence synthesis work. In addition, we would like to support WHO positions that are aligned with Cochrane’s mission through statements for WHO Executive Board and World Health Assembly agenda items.
WHO guidelines are a global public good. They have a considerable impact across a wide range of settings. The substantial resources and expertise needed to develop such evidence-based guidelines mean that this cannot feasibly be done in each country or region. By collaborating closely with WHO, Cochrane can both contribute to this global good and ensure that our reviews are policy relevant and used widely.
The meeting discussions highlighted concrete strategies that we can take forward to further work on a mutually beneficial relationship. Many of the suggestions made concern a better alignment of the work of both organizations. Two concrete actions to strengthen this are:
- to link a contact person from Cochrane Groups to the relevant WHO departments (where these connections are not yet existing): and
- for the GRC to publish their guideline timelines, so that Cochrane Groups can respond in a timely manner.
We will work with the WHO on a detailed plan of next steps, which will also help inform the review of our official relations with WHO and the development of a new plan of work in 2018.