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Crossing borders: the PACK experience of spreading a complex health system intervention across low-income and middle-income countries
  1. Ruth Cornick1,
  2. Camilla Wattrus1,
  3. Tracy Eastman1,
  4. Christy Joy Ras1,
  5. Ajibola Awotiwon1,
  6. Lauren Anderson1,
  7. Eric Bateman1,
  8. Jorge Zepeda2,
  9. Merrick Zwarenstein3,
  10. Tanya Doherty4,
  11. Lara Fairall1
  1. 1 Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
  2. 2 Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
  3. 3 Western University, Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, London, Ontario, Canada
  4. 4 South African Medical Research Council and Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
  1. Correspondence to Dr Ruth Cornick; ruth.cornick{at}


Developing a health system intervention that helps to improve primary care in a low-income and middle-income country (LMIC) is a considerable challenge; finding ways to spread that intervention to other LMICs is another. The Practical Approach to Care Kit (PACK) programme is a complex health system intervention that has been developed and adopted as policy in South Africa to improve and standardise primary care delivery. We have successfully spread PACK to several other LMICs, including Botswana, Brazil, Nigeria and Ethiopia. This paper describes our experiences of localising and implementing PACK in these countries, and our evolving mentorship model of localisation that entails our unit providing mentorship support to an in-country team to ensure that the programme is tailored to local resource constraints, burden of disease and on-the-ground realities. The iterative nature of the model’s development meant that with each country experience, we could refine both the mentorship package and the programme itself with lessons from one country applied to the next—a ‘learning health system’ with global reach. While not yet formally evaluated, we appear to have created a feasible model for taking our health system intervention across more borders.

  • keywords
  • public health
  • health policy
  • health systems

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  • Handling editor Seye Abimbola

  • Contributors 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 KTU has received funding from various sources for PALSA PLUS and PACK localisation support work. The International Development Research Centre (IDRC) and Canadian International Development Agency (CIDA) funded work in Malawi and the Medical Education Partnership Initiative (MEPI) supported the PACK Botswana localisation, specifically funded by US’ HRSA (Health Resources & Services Administration). The PACK Nigeria pilot was funded through the Nigerian State Health Investment Project (NSHIP), a World Bank-assisted initiative led by Nigeria's National Primary Health Care Development Agency. The localisation of the PACK Nigeria guide and training resources was funded through a central NSHIP technical assistance budget managed by Oxford Policy Management. The KTU mentorship of the Ethiopian localisation work was supported by the United Kingdom’s National Institute of Health Research (NIHR) using Official Development Assistance (ODA) funding (NIHR Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King's College London (16/136/54)). The KTU received funding to support the development of the PACK localisation package from the Peter Sowerby Charitable Foundation. Additional funding was provided by the BMJ Publishing Group and University of Cape Town Lung Institute. Tanya Doherty’s time was supported by the South African Medical Research Council. PACK receives no funding from the pharmaceutical industry.

  • Disclaimer The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the English Department of Health.

  • Competing interests We have read and understood BMJ policy on declaration of interests and declare that RC, CW, AA, CR, LA, EB and LF are employees of the KTU. T Eastman is a contractor for both KTU and BMJ, London, UK. JZ is an ex-employee of the City Health Department, Florianópolis, Brazil and a current holder of full-time PhD studentship from the Brazilian research agency CNPq. MZ is an employee of the Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. TD is an employee of the South African Medical Research Council. EB reports personal fees from ICON, Novartis, Cipla, Vectura, Cipla, Menarini, ALK, ICON, 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 co-fund 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 health care 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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