VIEWPOINT 120 NATURE CLINICAL PRACTICE GASTROENTEROLOGY & HEPATOLOGY MARCH 2008 VOL 5 NO 3 www.nature.com/clinicalpractice/gasthep How can global guidelines have an impact on, support or help to change health policy? There are considerable infrastructural limitations to the provision of health care throughout the world, especially in poorer nations where health care has to compete for scarce resources with other national needs and priorities. 1 Needs and priorities related to health care differ greatly throughout the world: malaria, for example, might not be a major priority in Canada but it is in many African countries. For global guidelines to gain acceptance and influ- ence health policy at national, regional and local levels, local involvement in their development and implementation is essential. The ability of a global guideline to have an impact on health care in a developing country will also be critically influ- enced by the availability of resources, by an under- standing by the intended target population of the guideline-making process and a realization that benefits will accrue through their participation in the implementation of the guideline. Although evidence-based guidelines from wealthy countries define optimal goals for resource-constrained countries, these countries commonly lack the fundamental infrastructure that is required for direct implementation. This is amply illustrated by experience with breast cancer in countries with limited resources. 2 Breast cancer mortality rates are highest among economically disadvantaged countries. Low- income and middle-income countries (LMCs) typically lack the major components of health- care infrastructure and resources necessary to implement improved methods for the early detec- tion, diagnosis and treatment of breast cancer. 3 Evidence-based guidelines can define strategies by which practical, economically-achievable, incre- mental improvements can be sequentially intro- duced within the context of resource constraints to create measurable improvements in health-care administration and outcome. Guidelines for breast health care, published in 2006 and made available in an unrestricted fashion on the internet, provide evidence-based expert consensus guidelines that specifically address issues Can global guidelines change health policy? M Fried*, EMM Quigley, RH Hunt, G Guyatt, BO Anderson, DJ Bjorkman, MJG Farthing, SS Fedail, R Green-Thompson, J Hampton, J Krabshuis, L Laine and R Horton For details of the authors’ affiliations and biographies go to the article online. Correspondence *Division of Gastroenterology and Hepatology University Hospital Zürich Raemistrasse 100 CH-8091 Zürich Switzerland michael.fried@usz.ch Received 2 March 2007 Accepted 26 September 2007 Published online 13 November 2007 www.nature.com/clinicalpractice doi:10.1038/ncpgasthep0998 of implementation in LMCs. The Breast Health Global Initiative (BHGI) guidelines define compre- hensive pathways for LMCs to address early detec- tion, diagnosis, treatment and health-care systems for breast health care. The BHGI guidelines stratify resources into four levels (basic, limited, enhanced and maximal), making the guidelines applicable to countries of differing economic capacities. The Institute of Medicine identifies the BHGI approach as a model for developing resource-sensitive guidelines that could be applied to other cancers or chronic diseases for which effective treatments are available. 4 The development of effective global guidelines requires the early participation of all stakeholders, including health policy-makers. For a guideline to achieve acceptance, health policy-makers need to be given clear messages about its potential impact in order to help them prioritize scarce resources. These messages should include a cascade, which is a collection of related diagnostic and treat- ment options arranged hierarchically in terms of conditions and available resources. 5 Considerable effort and resources must be assigned to the education of all those who might be involved in the implementation of guidelines, from health-care workers and their administrators to the community and patients. In relation to the latter, the inclusion of patient advocacy groups in the process of guideline construction and implementation might be of considerable value. Opinions are divided as to whether the bio- medical industry should be involved in the development and implementation of global guide- lines. Reflecting widespread anxieties in regard to relationships between industry and academia in biomedical research, 6 some would contend that experience has shown that the direct involvement of industry in guideline development leads to consid- erable skepticism of guideline recommendations. It is not enough for guideline authors to disclose relationships with industry in order to convince the public that their recommendations are unbiased. This approach might not be sufficient to inform a guideline user whether or not the participant