Empowering primary health care workers

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In most low-and-middle income countries primary care is constrained by a lack of adequately skilled health workers.

Providing affordable and accessible primary health care is critical in achieving the United Nations led Sustainable Development Goals. The challenges of primary care are present in both developed and developing countries, but the burden is far greater in health systems where healthcare workers have to provide care with limited access to evidence based data.

Bridging the divide between policy and practice in primary healthcare

In South Arica, one institution has decided to shift their focus to primary care and increase the impact of primary care practitioners. The Knowledge Translation Unit (KTU), a health systems research unit based at the University of Cape Town Lung Institute has spent 16 years developing the Practical Approach to Care Kit (PACK). PACK is a programme designed to enable healthcare practitioners to manage symptoms and diagnose conditions commonly seen in primary care. The programme has witnessed tremendous achievements in South Africa with countrywide scale ups – it has been implemented in over 2000 clinics and is being used by more than 20,000 healthcare workers.

Four randomised control trials in South Africa illustrate the ability of PACK to deliver improvements in: case detection rates, prescribing patterns, referral of severe and complex cases, and how health care is being used.

PACK model – 4 key principles:

  • The PACK guide: An evidence and policy based clinical decision tool that covers 40 common symptoms and 20 acute and chronic conditions seen among adults attending primary care clinics. It is underpinned by clinical algorithms that guide the primary healthcare practitioners.
  • The PACK training programme: The implementation strategy is based on educational outreach completed via team and case-based training to create familiarity with the clinical decision tool and to emphasise areas where practice needs to change. The training programme is based on cascade training allowing for rapid scale up across different sites.
  • Health systems improvement programme: This pillar assess the referral pathways, prescribing responsibilities and addresses methods for task shifting across different cadres of primary care practitioners.
  • Monitoring and evaluation of the implementation: This pillar involves data audits, programme evaluation and research trials.

The clinical decision tool content is ‘generic’ enough that it can be tailored to meet the needs of primary healthcare systems in other countries. Localisation by health practitioners within specific countries allows the tool to meet local regulations and clinical protocols. PACK has previously been localised for Botswana and Malawi. PACK undergoes annual revisions to ensure information is in line with current evidence. Since 2015 updating guidelines with new evidence updates was made possible by KTUs partnership with BMJ, one of the world’s leading healthcare knowledge providers. In 2016, PACK Global Adult 2016/17 was launched and is available in e-Book and print format.

Lessons to be learnt:

  • KTU has developed a mentorship package to support the in-country localisation of PACK. Health practitioners from other countries should take advantage of this mentorship to find ways to implement PACK into their own healthcare system.


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Author Information

Kathryn Schulz joined The New Yorker as a staff writer in 2015. In 2016, she won the Pulitzer Prize for Feature Writing and a National Magazine Award for “The Really Big One,” her story on the seismic risk in the Pacific Northwest.

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