PACK is more than just a clinical practice guide and its implementation requires robust engagement and support from Health Managers,
clinicians and ultimately the patients they serve.
More About PACK Nigeria
In 2014 a survey commissioned by the Nigerian Federal Ministry of Health highlighted serious shortcomings in the quality of clinical care available at primary health care level. Only 37% of primary health care workers were able to correctly diagnose seven tracer cases and only 17% recommended appropriate treatments. Prompted by discussions at the World Bank Nigeria, BMJ proposed a pilot of PACK Nigeria to see whether clinicians could improve their ability to manage their adult patients if they received a package of support comprising a comprehensive clinical practice guide and a structured programme of on-site, in-service training and monitoring (the Practical Approach to Care Kit or PACK).
The PACK programme has been developed, refined, tested and scaled-up over a period of two decades by the University of Cape Town’s Knowledge Translation Unit (KTU). It currently supports more than 30,000 nurses working in South Africa’s 3,500 primary care clinics. BMJ partnered with KTU and the Nigerian NGO, HRI West Africa (HRIWA), to localise PACK for Nigeria and pilot it in 51 primary care facilities in the three states participating in the Nigerian State Health Investment Project (NSHIP): Adamawa (22), Nasarawa (11) and Ondo (18). Localisation and preparatory work was supported by BMJ and Oxford Policy Management (OPM), and training and implementation at state level by the states themselves. This report covers the 16 month period during which the PACK programme was localised to the Nigerian context and implemented in the 51 primary health centres (PHCs).
From May to November 2016 HRIWA, with support from KTU and BMJ, localised the PACK guide and training materials, aligning content with Nigerian regulations, clinical protocols and available diagnostic tests, equipment and medications. The result is PACK Nigeria Adult, a single, integrated, comprehensive, evidence-informed, policy-aligned clinical guide to support all cadres of health care worker managing adult patients in PHCs in Nigeria.
Before training commenced the State Primary Health Care Development Agencies (SPHCDAs) in the three states were provided with a list of all the medicines, tests and equipment included in PACK so that they could ensure that the necessary resources were in place. They were also encouraged to develop a communications plan to help promote PACK not just to the clinicians themselves but also to all those who are responsible for the delivery of primary health care services in the state and to the patients and communities they serve.
The PACK Nigeria training was delivered via a cascade approach: HRIWA’s National Lead Trainers, with support from KTU, trained 4 Master Trainers from each state during a 4-day workshop in Abuja in February 2017. The Master Trainers then returned to their own state where they led a 4-day workshop to train the Facility Trainers at the end of the month. The Facility Trainers in turn returned to their own PHC where they have since organised every fortnight a short, interactive, team-oriented training session covering a different clinical case. Throughout the course of the pilot, training statistics from attendance registers and feedback from individual participants was collected and collated. This was supplemented by focus group discussions held with selected facility staff in each state at the end of the pilot. Halfway through the pilot a digital version of the guide on 10” tablets (ePACK) was introduced to 20 facilities.
A total of 354 clinicians across all three states were trained on the PACK Nigeria Adult guide, with 90% of them completing all 12 cases during the short pilot period. Response from clinicians, managers and trainers from all three states was overwhelmingly positive. Clinicians consistently reported that they felt empowered and clear about their scope of practice and how they related to other cadres within primary care, which has encouraged multidisciplinary teamwork in the PHC. PACK Nigeria has been widely praised for its ease of use and for the confidence it brings clinicians in the diagnosis and treatment of their patients: “Using PACK builds my confidence. There is no ambiguity, it’s just straightforward. And it motivates my staff, my colleagues.” This has translated into very high usage levels of PACK: 73% of clinicians reported using PACK in almost every consultation and 93% using PACK in the majority of their consultations. Clinicians have also reported that PACK Nigeria has improved their clinical knowledge and skills. With respect to clinical decision-making the mean total test score prior to training was 3.7 and this increased by the end of the pilot to a mean of 6.9, an improvement of 86%. This improvement has been most pronounced in the reduction of polypharmacy and more appropriate use of laboratory tests observed in all three states since the introduction of PACK Nigeria: “Before PACK I used to prescribe 6-7 drugs per patient, but now I prescribe only 1-2 drugs per patient”. In Adamawa managers reported that the routine prescription of Amoxil antibiotics alongside ACTs (Artemisinin-based Combination Therapy) in the treatment of malaria has been eliminated in Fufore Local Government Area (LGA) since the pilot began. 63% of clinicians agreed that PACK has helped to reduce the amount of time spent with patients, but 34% have reported that patient consultations are taking longer. This issue appears to have diminished as the pilot progressed and familiarity with the PACK Nigeria guide increased. Some clinicians also expressed concern about the reaction of patients to their use of a “book” during consultations. The digital version of PACK did much to address both concerns as it was found to be quicker to use and was much more favourably received by patients: “Even my patients are having confidence on my using ePACK”. In either event it will be important to sensitise communities to PACK before it is used in their PHC. Even before the end of the pilot, managers from all three states indicated their intention to scale up PACK state-wide. Dr Adis, Executive Secretary, Nasarawa SPHCDA, stated that “PACK Nigeria is an important tool to help strengthen the quality of care in Nasarawa state.” Dr Akanbiemu, Executive Secretary, Ondo SPHCDB, described PACK Nigeria as a “veritable way of ameliorating the critical human resources challenges in our Health Centres”. Furthermore, the National Primary Health Care Development Agency has indicated that they would now like PACK Nigeria to be introduced nationally. Demand for PACK Child, currently being piloted in South Africa, was ubiquitous and is urgently needed in a country where children account for some 70% of primary care contacts.
In the words of Dr Belel, Executive Chairman, Adamawa SPHCDA, PACK Nigeria is a “high-impact intervention”. It has the potential for rapid widespread scale-up and support of evidence-informed primary care in Nigeria. Efforts to scale-up PACK in-service and in pre-service curricula require state-level leadership and sustained commitment to ensuring availability of essential medications and tests, monitoring and evaluation. This should be supported by a national platform to promote PACK Nigeria, provide annual guide and training updates, new content (e.g. PACK Child), digital innovations and work with researchers to evaluate medium to long-term impacts on quality and cost of primary care.