Primary healthcare bible piloted in Brazil

Primary healthcare practitioners call it their bible. You'll find a well-thumbed copy of the Practical Approach to Care Kit (PACK) in clinics all over South Africa. Developed over the past 16 years by UCT's Knowledge Translation Unit (KTU) at the Lung Institute, the comprehensive clinical management tool has become indispensable to front-line nurses and doctors. It's now being piloted in Brazil.

In a nutshell, the PACK is a tool that helps healthcare practitioners to diagnose and manage common conditions. It covers 40 common symptoms and 20 conditions, such as cardiovascular disease, respiratory disease, tuberculosis, HIV/AIDS, women's health, and end-of-life care. It's all integrated in one handbook.

Tailored versions of PACK (sometimes by different names) have been developed for several developing countries, including Brazil, Malawi, Botswana and Mexico. There are plans to roll it out in Ethiopia, and it's also being piloted in Nigeria.

“We're in a phase of global expansion,” said Emeritus Professor Eric Bateman, a member of the KTU leadership team.

Collaboration and research

Its success has been built on collaboration, evidence-based research and outreach, said Bateman. With its team of 40, headed by Associate Professor Lara Fairall, the KTU has published over 40 papers on the PACK approach in the unit's 15 years. In South Africa more than 500 000 copies have been distributed.

It plugs a huge gap in clinical skills and patient care.

“A lot of work is put in at manager level to improve primary healthcare facilities and services, but we felt that the neglected parties were the people at the coalface – the front-line nurses and doctors who daily are faced with an enormous burden of clinical problems,” explained Bateman.

“It's difficult to tell planners what it means to nurses who are hard-pressed and often alone with no doctor for miles, and not sure who to refer or how to treat. PACK is a lifesaver and empowers them.”

In many developing countries, primary healthcare is nurse led. South Africa has several times more nurses than doctors, especially in the rural areas where the team focused first.

Importantly, PACK distinguishes between urgent and non-urgent cases. It's also colour-coded to define actions nurses can take and actions doctors can take, which eases the decision-making burden for nurses. Training is presented on-site at clinics.

Having all the essential information in one guide also encourages system change, said Bateman. Primary healthcare staff are faced with a plethora of information from apps, guides and other resources – a massive pile of often confusing material − and often contradictory instructions.

“The KTU has correlated all the information and this helps the authorities to ensure that the relevant drugs are available.”

(From left, back) Prof Alvaro Cruz, Emer Prof Eric Bateman and Prof Rafael Stelmach. (From left, front) Knowledge Translation Unit staffers Faye Eshraghi (unit manager), Lauren Anderson (head of training), Assoc Prof Lara Fairall (unit head), and Dr Ruth Cornick (head of the content team, clinical guide). Photo Michael Hammond.

Meeting global need

The KTU team see this as a global need. PACK is updated annually to comply with local clinical policy, regulations and essential drug lists, and is translated where necessary. It incorporates regular evidence updates from the British Medical Journal Evidence Centre and other credible sources, including the World Health Organisation, to ensure that it is relevant and provides the latest best-practice guidance.

The good news is that the KTU recently completed a child version of the PACK (sponsored by the Children's Hospital Trust), and work is underway to develop one for adolescents and one for community health workers.

For the past three years the team has worked with Brazilian researchers to produce a Brazilian version of the PACK, which is being piloted there.

“There's enthusiastic uptake and we expect PACK to be rolled out in other states in Brazil,” said Bateman.

To this end, two collaborators visited the KTU: Professor Rafael Stelmach, a pulmonologist in the Department of Medicine, University of Sao Paulo, and Professor Alvaro Cruz of the Faculty of Medicine, Federal University of Bahia, Brazil.

This south–south collaboration has been going for several years after UCT and the University of Sao Paulo signed a letter of cooperation in 2014, encouraging active collaboration.

“We are supervising PhD students from Brazil locally and they visited UCT for a writing workshop,” said Bateman.

Since the start of the collaboration, 11 research papers have been identified.

“We have an active research collaboration, sharing the mentorship of students, and we've applied for several grants together as we see this collaboration as a long-standing one. We're working to create capacity in Brazil and we have our collaborators there trained in our methods so that they can keep their version [of PACK] up to date.”

Bateman says the team would like to see similar programmes adapted or localised for every country in need.

“It's not just about producing a PACK; it needs to be localised or adapted to local need, incorporating the policies of the relevant governments, and to be evidence-based.”