For the primary health worker in a low/middle-income country (LMIC) setting, delivering quality primary care is challenging. This is often complicated by clinical guidance that is out of date, inconsistent and informed by evidence from high-income countries that ignores LMIC resource constraints and burden of disease. The Knowledge Translation Unit (KTU) of the University of Cape Town Lung Institute has developed, implemented and evaluated a health systems intervention in South Africa, and localised it to Botswana, Nigeria, Ethiopia and Brazil, that simplifies and standardises the care delivered by primary health workers while strengthening the system in which they work. At the core of this intervention, called Practical Approach to Care Kit (PACK), is a clinical decision support tool, the PACK guide. This paper describes the development of the guide over an 18-year period and explains the design features that have addressed what the patient, the clinician and the health system need from clinical guidance, and have made it, in the words of a South African primary care nurse, ‘A tool for every day for every patient’. It describes the lessons learnt during the development process that the KTU now applies to further development, maintenance and in-country localisation of the guide: develop clinical decision support in context first, involve local stakeholders in all stages, leverage others’ evidence databases to remain up to date and ensure content development, updating and localisation articulate with implementation.
- public health
- health systems
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Handling editor Seye Abimbola
Contributors Led by RC, SP, CW, AA, EC and JH are the KTU content team that developed and maintain the PACK guide and related tools. LF, with support from EB and MZ, conceptualised the PACK approach. TD provided editorial support to this paper. RC wrote the first draft of the paper. All authors contributed intellectual content, edited the manuscript and approved the final version for submission.
Funding The initial expansion of PALSA PLUS to Primary Care 101 and then PACK was funded by the University of Cape Town Lung Institute, the South African National Department of Health and the Chronic Disease Initiative in Africa (CDIA) through an award from the National Heart, Lung and Blood Institute for Global Health Activities in Developing Countries to Combat Non-Communicable Chronic Cardiovascular and Pulmonary Diseases. The KTU received funding for the development of the evidence database for the PACK guide and linkage to the BMJ’s Best Practice and WHO guidance from the Peter Sowerby Charitable Foundation. The Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) funded a writing retreat that supported the development of this paper. TD’s time was supported by the South African Medical Research Council. PACK receives no funding from the pharmaceutical industry.
Competing interests JLH is an ex-employee of the KTU. TD is an employee of the South African Medical Research Council. MZ is an employee of the Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. EB reports personal fees from ICON, Novartis, Cipla, Vectura, Cipla, Menarini, ALK, Sanofi Regeneron, Boehringer Ingelheim and AstraZeneca, and grants for clinical trials from Novartis, Boehringer Ingelheim, Merck, Takeda, GlaxoSmithKline, Hoffmann le Roche, Actelion, Chiesi, Sanofi-Aventis, Cephalon, TEVA and AstraZeneca. All of EB’s fees and clinical trials are for work outside the submitted work. EB is also a member of Global Initiative for Asthma Board and Science Committee. Since August 2015 the KTU and BMJ have been engaged in a non-profit strategic partnership to provide continuous evidence updates for PACK, expand PACK-related supported services to countries and organisations as requested, and where appropriate license PACK content. The KTU and BMJ cofund core positions, including a PACK Global Development Director, and receive no profits from the partnership. PACK receives no funding from the pharmaceutical industry. This paper forms part of a Collection on PACK sponsored by the BMJ to profile the contribution of PACK across several countries towards the realisation of comprehensive primary healthcare as envisaged in the Declaration of Alma Ata, during its 40th anniversary.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
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