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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.106 n.1 Cape Town Jan. 2016 



South African Guidelines Excellence (SAGE): What´s in a name?






Quality of healthcare can be understood to encompass a number of dimensions, including effectiveness, efficiency, accessibility, patient- centredness, equity and safety.[2] SA's call for primary healthcare re-engineering suggests an acute awareness of local challenges. The planned restructuring, including the National Health Insurance initiative, is a means for reducing inequality in the provision of healthcare, which will require new approaches to healthcare delivery, with greater emphasis on health promotion and preventive activities.[3,4] These changes necessitate a collaborative approach for achieving improvements in key health processes and outcomes, as well as changes in clinician and patient behaviours, all underpinned by innovative interventions.[5] In the changing healthcare system, healthcare providers need clear, trustworthy guidance on how best to care for their patients so that all can reasonably reach the ideals of quality in healthcare. High-quality, evidence-informed clinical practice guidelines (CPGs) are potentially reassuring tools for healthcare providers, as they are a means of bridging the gap between policy, best practice, local contexts and patient choice.

CPGs have long been upheld as an essential part of quality medical practice. 'Clinical guidelines are statements that include recommendations intended to optimise patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.[6]

CPGs have a range of purposes, intended to improve the efficiency and cost-effectiveness of health system utilisation and to decrease costly and preventable mistakes. They generally include statements of expected practice, and provide benchmarks or standards against which individuals may audit and potentially improve their practices, or guidance with regard to undertaking particular tasks.[7] Internationally, over the past decade there has been a growing volume of research evidence around CPGs, including the processes of guideline development, adaptation, contextualisation, implementation and evaluation. There are detailed processes available for the development of CPGs, but there is no standard approach. Notably, there are well-credentialled international and national guideline development groups, including the World Health Organization,[8] the Scottish Intercollegiate Guidelines Network,[9] the National Institute for Health and Care Excellence[10] and the National Health and Medical Research Council,[11] each with its own approach to guideline construction and writing, usually described in a guideline development manual.

Globally and locally, potentially many hundreds more groups (such as health departments, insurers and other healthcare organisations, professional associations, hospitals, specialty colleges and even small unaffiliated groups of individuals) have attempted the task of producing guidelines with the purpose of improving or standardising local clinical practice. They often use their own interpretations of the best way to construct and write clinical guidelines. Historically, CPGs were built mostly on expert opinion, which included variable (and often selective) reference to research evidence.[12,13] Such guidelines are still found today, albeit in decreasing numbers. Better and more transparently constructed evidence-informed approaches integrated with expert opinion and patient values have gained acceptance as the best approach to clinical guideline development. To support this progress, in 2011 the Institute of Medicine (IOM) introduced eight standards for guideline development (IOM 2011), the Guidelines International Network produced 11 relatively similar standards,[14] and McMaster University compiled a checklist of 18 topics and 146 items to guide developers.[15]


South African Guidelines Excellence (SAGE): What's in a name?

SA has been a contributor to CPG development and implementation for several decades. Guideline development occurs at national, provincial and hospital levels. In addition, professional societies have played an important role, developing guidance based on their areas of expertise. For example, the National Department of Health spearheads an Essential Medicines Programme that drives the development of standard treatment guidelines to inform rational prescription at all levels of care (primary, secondary and tertiary, quaternary) in an equitable, cost-effective manner throughout the country. Regionally, there is evidence that SA is a node of technical expertise in this field, with the quality of our guideline development exceeding that of our regional neighbours in the Southern African Development Community.[16] However, against a global backdrop SA's guidelines do not yet demonstrate all the aspects of expected guideline quality indicators according to recognised global standards. To address concerns with the quality of CPGs, the SAMJ has introduced a Guideline Review Committee to provide peer review before publication in the Journal.[17]

In addition to contributions to guideline development, SA researchers are global leaders in research into implementation, conducting high-quality cluster trials of complex interventions evaluating guideline uptake. For instance, the Knowledge Translation Unit at the University of Cape Town has conducted pragmatic trials evaluating outreach education and task shifting of care from doctors to other health professionals, compared with standard care for implementing guidelines for respiratory conditions, including tuberculosis and more recently HIV.[18-20] The guidelines, developed and implemented by this team for SA, are now being rolled out to other settings in Botswana and Malawi, where a similar trial to contextualise the effectiveness of the educational intervention has been tested.[21] This research team is currently expanding its work to include guideline implementation for a package of primary care conditions, the results of which are impacting on clinical care at primary care level throughout SA,[22] and has recently gone into partnership with the British Medical Journal.[23]

Despite these innovative SA research activities into CPG development and implementation, there is still limited knowledge of the overall context and processes of guideline development, adherence by clinicians to clinical guidelines, and factors that could improve accessibility and use of guidelines in the local healthcare context. Our work is based on the premise that high-quality, evidence- informed CPGs offer a cogent and persuasive way of bridging the gap between evidence and best practice, local contexts and health provider behaviour. Understanding the current state of play in SA primary care CPG development and implementation can therefore pave the way for better-focused and more effective and efficient interventions to improve healthcare. Project SAGE (South African Guidelines Excellence) is a 3-year research project, funded by the South African Medical Research Council through the Flagship Project scheme ([24] The overarching goal of the Flagship Projects is to support large-scale, innovative, interdisciplinary research projects to address health problems in SA.

Project SAGE is an innovative research partnership between Cochrane South Africa, the Centre for Evidence-based Health Care and the Department of Physiotherapy in the Faculty of Medicine and Health Sciences, Stellenbosch University, and the International Centre for Allied Health Evidence, University of South Australia. Project SAGE has five goals that aim to improve the quality and reach of SA primary care CPGs (Fig. 1). Using stakeholder-driven processes, SAGE will provide tools to assist effective SA CPG activities in developing, adapting, adopting, contextualising and implementing primary care CPGs.[24]

In a resource-limited setting such as SA, where access to resources for health is limited, ensuring the best use of effective and cost- effective primary care diagnostics and treatments is key to reducing waste, improving access and hence improving quality of care.[25] CPGs should be seen to transparently and systematically consider best research evidence to produce believable recommendations, which can then be credible vehicles for knowledge translation. Once there is agreement on what constitutes SA best practices in CPG development, implementation and evaluation, primary care clinicians can be assured that the CPGs developed and implemented in SA will support best practice, are achievable by all end users, and will lead to improved patient care.


Tamara Kredo, Shingai Machingaidze

Cochrane South Africa, South African Medical Research Council, Tygerberg, Cape Town, South Africa

Quinette Louw

Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa, and Cochrane South Africa, South African Medical Research Council, Tygerberg

Taryn Young

Centre for Evidence-Based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa, and South African Medical Research Council, Tygerberg

Karen Grimmer

International Centre for Allied Health Evidence, University of South Australia, Adelaide, Australia, and Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa



1. Lehlola P. Statistics South Africa. Poverty Trends in South Africa: An Examination of Absolute Poverty Between 2006 and 2011. Pretoria: SSA, 2014.         [ Links ]

2. World Health Organization. Quality of Care - A Process for Making Stratetic Choices in Health Systems. Geneva: WHO, 2006.         [ Links ]

3. National Department of Health. The 10 Point Plan Medium Term Strategic Framework 2009-2014. 2009. (accessed 15 August 2015).         [ Links ]

4. Matsoso P, Fryatt R. National Health Insurance: The first 16 months. S Afr Med J 2013;103(3):156-158. []        [ Links ]

5. Mayosi BM, Flisher AJ, Lalloo UG, et al. The burden of non-communicable diseases in South Africa. Lancet 2009;374(9693):934-947. []        [ Links ]

6. Graham R, Mancher M, Wolman D, Greenfield S, Steinberg E. Clinical Practice Guidelines We Can Trust. Washington, DC: Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice Guidelines/National Academies Press, 2011:15.         [ Links ]

7. Woolf SH, Grol R, Hutchinson A, et al. Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. BMJ 1999;318(7182):527-530. []        [ Links ]

8. World Health Organization. WHO Handbook for Guideline Development. Geneva: WHO, 2008.         [ Links ]

9. Scottish Intercollegiate Guidelines Network. SIGN 50: A Guideline Developer's Handbook. 2008. (accessed 7 January 2011).         [ Links ]

10. National Institute for Health and Clinical Excellence. The Guidelines Manual. November 2008. London: National Institute for Health and Clinical Excellence. (accessed 15 August 2015).         [ Links ]

11. National Health and Medical Research Council. A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines. Canberra, Australia: National Health and Medical Research Council, 1999.         [ Links ]

12. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodo- logical quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999;281(20):1900-1905.         [ Links ]

13. Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice guidelines developed by specialty societies: The need for a critical appraisal. Lancet 2000;355(9198):103-106. []        [ Links ]

14. Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P; Board of Trustees of the Guidelines International Network. Guidelines International Network : Toward international standards for clinical practice guidelines. Ann Intern Med 2012;156 (7):525-531. []        [ Links ]

15. Schünemann HJ, Wiercioch W, Etxeandia I, et al. Guidelines 2.0: Systematic development of a comprehensive checklist for a successful guideline enterprise. CMAJ 2014;186(3):E123-E142. []        [ Links ]

16. Kredo T, Gerritsen A, van Heerden J, et al. Clinical practice guidelines within the Southern African Development Community: A descriptive study of the quality of guideline development and concordance with best evidence for five priority diseases. Health Res Policy Syst 2012;10(1):1. []        [ Links ]

17. Wiseman R, Cohen K, Gray A, et al. AGREE to disagree: Critical appraisal and the publication of practice guidelines. S Afr Med J 2014;104(5):345-346. []        [ Links ]

18. Fairall LR, Zwarenstein M, Bateman ED, et al. Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: Pragmatic cluster randomised controlled trial. BMJ 2005;331(7519):750-754. Erratum in: BMJ. 2005;331(7525):1120. Myers, Pat [corrected to Mayers,         [ Links ] Pat] []

19. Zwarenstein M, Fairall R, Lombard C, et al. Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial. BMJ 2011;342:d2022. []        [ Links ]

20. Fairall LR, Bachmann MO, Lombard C, et al Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): A pragmatic, parallel, cluster-randomised trial. Lancet 2012;380(9845):889-898. []        [ Links ]

21. Schull MJ, Cornick R, Thompson S, et al. From PALSA PLUS to PALM PLUS: Adapting and developing a South African guideline and training intervention to better integrate HIV/AIDS care with primary care in rural health centers in Malawi. Implement Sci 2011;6:82. []        [ Links ]

22. Knowledge Translation Unit. Evidence on the effectiveness of the Primary Care 101 guideline. (accessed 15 August 2015).         [ Links ]

23. Providing guidance to empower LMIC heath teams. (accessed 10 February 2015).         [ Links ]

24. Machingaidze S, Kredo T, Louw Q, Young T, Grimmer K. South African Guidelines Excellence (SAGE): Clinical practice guidelines - quality and credibility. S Afr Med J 2015;105(9):743-745. []        [ Links ]

25. Chinnock P, Siegfried N, Clarke M. Is evidence-based medicine relevant to the developing world? PLoS Med 2005;2(5):e107. []        [ Links ]



T Kredo

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