Table 4 Guidelines intertwined in WHO’s roles

Communicator

WHO communicated freely available information and guidance to “the Ministry of Health partners within the countries, but it is also available to be given to our various partners … civil society or non-state actors such as NGOs or academic universities as, for example, they are implementing a project or carrying out a research study, they can easily access and use it for their own purpose” (Fiona, HQ staff). New and updated WHO guidelines were often disseminated in this process. Before the countries could consider implementation, the offices would aim to communicate the best available practices and recommendations

Promoter

WHO often worked to build a strong case for their guidelines’ recommendations making their recommendations specific to the country’s context. For example, this involved conducting “not just kind of a cost benefit analysis but rather cost efficiency analysis, the value for money” for particular programmes (e.g. medication subsidy on the national insurance scheme) (Nicole, Country Office staff). In helping conduct these economic analyses, WHO built a strong case for the country to increase medication access and, in turn, to enable practice according to guidelines (e.g. prescribing effective treatments)

Convener

WHO was a convener of different parties, holding meetings on international, regional and national levels. Often, this was done in the process of discussing and implementing a policy change related to a WHO guideline. “Most of the meeting was sharing among the eight countries on how they, for instance, adapt the guidelines to policy — what their policies look like, sound like. How they monitor, how they communicate and advocate for the implementation. How they actually implement those guidelines. So, it was very rich sharing among country counterparts” (Ellen, HQ staff). In convening different parties, WHO provided a forum for countries, health systems and stakeholders to learn from each other’s experience and overcome challenges together.

Authoritative source

Political role of WHO as an authoritative source of health information was demonstrated in a reciprocal way in the guideline implementation process. “It can be the case that a WHO country office or a Ministry of Health office requests a technical assistance visit from WHO headquarters and it’s for political reasons, it’s not because someone in Geneva has more expertise than someone in the country. It’s because they feel they require the kind of force of a Headquarters person saying something which can hold sway over a Ministry of Health” (Bill, HQ staff). This could improve the guideline’s adaptation and implementation. Conversely, the referral of guidelines as guarantors of legitimacy by countries could reinforce the authority of WHO.

Advocate

WHO’s role as an advocate to increase awareness or change public perception of particular conditions was often intertwined with guideline implementation. “One of the strategies that we need to think about is, as we support Ministries of Health, is to think about raising awareness at a committee level, so that has to be part of a global advocacy, so WHO can play a role in that raising that global advocacy, political commitment” (Fiona, HQ staff). Decreasing stigma in the public and the clinical setting was one of the ways to increase the use of guideline/evidence-based clinical care.