THE CASE IN SUPPORT OF SCALE-UP OF THE PACK NIGERIA PROGRAMME FOR PRIMARY HEALTH CARE (PHC) ACROSS THE COUNTRY TO TRANSFORM AND IMPROVE THE CARE DELIVERED AT THE POINT OF CARE.

INTRODUCTION:

In 2014, a survey1 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 and HRI Global (former HRIWA) PACK Nigeria was produced and piloted to see whether clinicians in PHC could improve their ability to manage their 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). 

Objective of PACK PROGRAMME                                                                                                                                 

The objectives of Introducing the PACK Nigeria programme in selected PHCs were: i) To standardise and strengthen the quality of primary healthcare delivery in Nigeria, and ii) To improve health seeking behaviour of the population through quality service delivery at the primary level of care, that leads to patient satisfaction and decision to seek care in PHCs.

PACK Nigeria for primary health care is a comprehensive single patient decision support tool for management of cases. It is evidence-informed tool for All PHC clinicians in Nigeria (JCHEW, CHEW, CHO/Nurse/Midwife, and Medical Officer). It was designed in South Africa ( PACK Global and Western Cape) over twenty years ago, and was brought to Nigeria and Localised to comply with Nigeria’s local policies, medication, tests, equipment, skills, treatment, including e.g. the Standing Orders (which is only for the Community Health Practitioners. (CHPs). The user tracks patient presentation and clinician decision making process (symptoms that prompt questions that lead to diagnosis): the way patients present in PHC: 3-step framework ‘Assess, Advise, Treat’ approach to managing chronic conditions. A RED BOX helps user to triage patients into Urgent / Non Urgent case!.   The Arrangement makes it easy-to-follow the algorithm, and concise language. For only ‘symptoms’ it is limited to one-page!, and for ‘chronic conditions’ 1-4 pages only. PACK is not a TextBook!, therefore PACK content is simply worded plain language, avoiding medical jargons, addresses users in active voice, deals with the patient in the ‘particular’ consultation, not all patients. Universally acknowledged to be User-friendly in all the states where it was piloted in 2017 ( Adamawa, Nasarawa and Ondo ) and scaled up in 2021 (Bauchi State).

Photo 6: PACK Nigeria Guide and other pillars ( Facility readiness, Onsite Training, M&E)  

For the PACK Nigeria Adult pilot, HRI Global  and partners provided case scenarios to cover the following eight conditions: acute diarrhoea with severe dehydration, malaria with anaemia, pneumonia, tuberculosis, Type 2 diabetes, hypertension, fever and pregnancy, in 4 modules covering: Communicable Diseases, Non-Communicable Diseases, Women’s Health and Mental Health.                                                         For the structured cascade training, and the in-built monitoring and evaluation activities, HRI Global provides the PACK Nigeria guide, structured training materials, and a package of mentorship and supportive supervision documents to ensure that the on-site, in-service training is implemented successfully and sustained. HRI Global also develops a database for collating and analysing the data from the facilities to ensure seamless Supportive Supervision, Mentoring, Monitoring and Evaluation (SSMM&E) activities. 

FEEDBACK FROM USERS OF PACK NIGERIA IN PHC (Pilot involved 354 clinicians in 51 PHCs in three NSHIP states over six months from February – August  2017) : (Quotations)

• “It is over 20 years or so since I last saw a project with such detail and step-by-step agenda for every activity as I have seen with PACK Nigeria Guide training”.( by Dr Belel, Chairman Adamawa SPHCDA, Abuja MT Training. Feb ‘17)
• “PACK Nigeria guide has great potential to improve clinical performance in primary health centres especially the concise and algorithmic arrangement of the content” (Master Trainers’ Participants , Abuja, Master Trainers Training)
• ‘’PACK is integrated, every cadre working from one guideline, evidence-informed, updated every two years, and designed for ease of use (algorithmic) is a good thing’’ (Master Trainers, Abuja)
• 73% providers used it in ALL consultations, 90% in most consultations
• “PACK is easier to follow since it is on one page for symptoms”
• “With PACK, I know where to stop and refer to next higher cadre”. 
• “Standing Order use to refer all to hospital, no stabilisation”.
• “Before PACK I used to prescribe 6-7 drugs per patient, but now I prescribe only 1-2 drugs per patient”.
• “I used to do many lab tests, but since PACK I now know when to request and it is necessary”
• “Now I don’t give many injections like before”
• ‘’use of PACK brings uniformity in diagnosis, care and treatment of our patients in PHC level’’. ‘’it strengthen pharmacy and laboratory sections of our health facility’’
• ‘’also cadres in health system know their limitations they treat and when to refer patients’’
• ‘’More use of the PACK guide is building my confidence and I can navigate better’ and saves time’
• “PACK guide is easier to use than Standing Order, symptoms on one page”
• ‘’PACK is good for group/team work’’. ‘’Thanks to PACK Nigeria’’
• ‘’I love my PACK’’ Song – lyrics by Ondo state PHC Users of PACK Nigeria.

FEEDBACK ABOUT PACK NIGERIA FROM STATE PHC CHAIRMEN / EXECUTIVE SECRETARY IN 2017: (Quotations)

• Dr Belel, Adamawa, added: ‘’PACK is a high impact intervention’’
• Dr M. Adis, Executive Chairman, Nasarawa SPHCDA : “PACK Nigeria is an important tool to help strengthen the quality of care in Nasarawa state.” 
• Dr F. Akanbiemu, Executive Secretary, Ondo SPHCDB: PACK Nigeria as a “veritable way of ameliorating the critical human resources challenges in our Health Centres”. 

Pre-service training :

As a result of the very strong and positive PACK pilot findings and acceptability, the former acting registrar of the Community Health Practitioner Registration Board (2017) had proposed that PACK Nigeria should be incorporated into the pre-service training curriculum for Community Health Practitioners (CHPs) i.e. JCHEW, CHEW, and CHO, for widespread adoption, including the trainers in the Colleges/Schools of Health Technology.

FEEDBACK FROM PHC STAFF IN BAUCHI STATE WHO USED PACK NIGERIA (Quotations)

i)‘by using PACK we diagnose malaria with RDTs and treat with ACTs’, and ‘we are not prescribing antibiotics for treatment of malaria by following PACK guide’, also 

ii) ‘we are not requesting many laboratory tests, because we go by what PACK says’ and   

iii) ‘we are also ‘practicing internal referral to the next higher cadre’, and ‘we refer to hospitals from Red Box for emergency cases’. 

iv) ‘by confirming diagnosis with RDTs using PACK, there is reduction of malaria relapse and patient return rate, since starting using PACK’, and   

v) ‘we like PACK to be scaled up to other PHCs in the state, because it is easy to use, to explain, and will help standardisation of care in the state’.

vi) ‘I used PACK to manage the patient, including the ‘CVD risk assessment’ page, and discovered the patient had obesity, high cholesterol and high CVD risk, so following the PACK recommendation, I advised patient on ‘exercises and low fat diet’, ‘no tablets’, and at the subsequent follow-up visit, the patient has become asymptomatic’; and

vii) ‘before PACK we wrote prescription using three times a day (TDS), but now we specify the interval in hours for taking the medicine (e.g. 6hrly or 12hrly) as contained in PACK’

viii) ‘PACK simplifies our work and patients are happy’. It is important to note that the reduction of antibiotics prescribing and reduction of the number of laboratory tests, have clear economic savings for patients, considering the high level of out-of-pocket expenses.

FEEDBACK ABOUT PACK NIGERIA FROM CHIEF EXECUTIVES IN BAUCHI STATE IN 2021: (Quotations)

1. The Hon Commissioner for Health, Dr Aliyu Maigoro who took part in the ‘Board Game’ and experienced how easy it was to get to use the Guide, described PACK as a ‘Game Changer’ for PHC. He declared that he ‘wants to see PACK scaled up to other PHCs beyond this first 20’. 
2. Dr. Rilwanu Mohammed, Executive Chairman,  BASPHCDA, said, ‘usually training programmes are conducted in cities/ headquarters, but PACK gives him joy, because there is a design of training to be conducted in the actual health facilities, onsite‟, and  he urged ‘trainees to take their training seriously, that they ‘should not take this as a joke‟!. He added that ‘PACK has come to stay in Bauchi State, for it will actually help our people to diagnose and treat our people‟, ‘I am happy that this has come‟.
3. The Executive Secretary, BASHCMA, Dr. Mansur M. Dada during his visits, said. He also said, that ‘twenty (20) facilities was too few for the Introductory Phase of PACK Nigeria, wished that many more were participating’,  ‘and that ’‘PACK is a Game changer, it will help us a lot in Bauchi State PHC to improve diagnosis and treatment of patients in PHC’’.                                                                                        

References:

1 Draft Country Report, Quality of Services Assessment and Resource Tracking Studies in Nigeria (Phase 1), Jan 2014 

2 Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Nigeria. BMJ Global Health Oct 2018, 3 (Suppl 5) e001079; DOI: 10.1136/bmjgh-2018-001079

3. Report on the Introduction Phase of the PACK Nigeria Programme in 20 Bauchi State Primary Health Centres, November 2020 to August 2021. HRI West Africa, Calabar, Nigeria.

4. Treatment Protocol for primary Health Care, Niger State Contributory Health Scheme (NGCHS). First Edition. 2020. HRI West Africa, Calabar, Nigeria

5. Treatment Guideline for Primary Health Care, Kaduna State Contributory Health Scheme (KDCHS), First Edition. 2020. HRI West Africa, Calabar, Nigeria.

6. Report on the Reactivation of the 12-Pillar Clinical Governance Programme in Cross River State Hospitals. March 2020 to 2021. HRI West Africa, Calabar, Nigeria.