Dear Neil, Naana and colleagues
I entirely agree that “International guidelines from WHO and other international health agencies are of limited use if they are not adapted/translated into actual policy and practice at national and facility levels. To be maximally useful, such guidelines need to be developed and presented in formats that are easy to use and that take account the realities of low-resource settings”. This is exactly the challenge that we are trying to address with the PACK (Practical Approach to Care Kit) programme.
As background: The PACK programme has been developed by the University of Cape Town Lung Institutes (UCTLI) Knowledge Translation Unit (KTU) in South Africa over the last 18 years, to equip and empower frontline primary healthcare (PHC) workers in LMIC’s. The users include clinically trained Community Health Workers, Health Officers, Nurses, Midwives, Pharmacists and Doctors. The ultimate goal is to strengthen primary healthcare systems & services, in order to enable more rapid achievement of UHC and the SDG’s.
The PACK “approach” brings together numerous well recognised best practices ie:
1) we use the WHO guidelines and other sentinel global guidelines as the starting point to create the “PACK Global guide” pages which focus on presenting symptoms and conditions most commonly seen in primary healthcare settings in LMICs,
2) we use the evidence change reports from the BMJ’s Knowledge Centre, to ensure that all of the latest globally published research (which is synthesised and updated on a daily basis by the BMJ’s Knowledge Centre), is leveraged to keep the “PACK Global guide” up to date
3) the resultant WHO + evidence-based “PACK Global guide” is presented in the format of symptom and condition focused pages, each starting with emergency management for that particular symptom or condition, followed by routine “assess, advise and treat” steps,
4) the pages are compiled in the format of clinical algorithms, checklists and calculations, presented in a highly user-friendly and accessible format, for rapid ease-of-use by frontline PHC clinicians,
5) we then work with in-country Health Ministry teams and their partners, including frontline PHC “clinical users”, to localise all of the “PACK Guide” content according to in-country standard treatment guidelines, essential medication lists, available diagnostic tests, health policy and regulations etc,
6) we recommend colour-coding the localised PACK Guide according to the scope-of-practice of the in-country clinicians
7) the local PACK Guide is translated if necessary
8) the UCT KTU team provide quality assurance (QA) and mentorship during the localisation and implementation process,
9) the final localised PACK Guide is made available to clinicians in print or digital format
10) “PACK Global guide” updates are delivered annually and we work with the in-country teams to support local guide updating,
11) the PACK programme has a comprehensive training and implementation component, with “Global Training materials” including a recommended training programme, Master trainer manuals, Facility trainer manuals, training videos and a bank of >50 training cases, all of these materials are localised for use in-country
12) we strongly recommend robust monitoring and evaluation of all PACK implementations, with associated research evaluation where appropriate and where funding for such evaluation is available,
13) the PACK programme has been developed by the UCTLI KTU team and implemented in the South African Ministry of Health PHC services over the last 18 years and forms part of the South African national “Ideal Clinic” programme,
14) the programme is run on a not-for-profit basis by both the UCTLI KTU and the BMJ, but funding is required to cover the “core costs” of producing and maintaining the Global PACK content and supporting in-country implementations to ensure that the programme remains sustainable,
15) the PACK programme is now being leveraged for adaptation, localisation and implementation in LMICs including Brazil, Nigeria and Ethiopia.
Through the PACK programme the UCTLI KTU and BMJ teams are aiming to share available evidence synthesis and knowledge translation guidance, training materials, tools, infrastructure and experience, which LMICs can leverage, adapt, localise and implement. This approach significantly decreases the combined effort, time and cost from the start-point of global evidence being produced – to the end-point of localised evidence being used by frontline clinicians in LMICs in their patient consultations.
The KTU & BMJ are in discussion with Health Ministry teams from several countries about starting new PACK implementations. If you’d like more information please have a look at the information on the websites at:
Nanna – I’ll contact you directly via e-mail. We would like to work with Health ministry-led primary healthcare teams in all LMICs to leverage global resources, and work as quickly as possible towards a Healthier World!!
HIFA profile: Tracy Eastman is a medical doctor and health manager. She is Director of International development of PACK (Practical Approach to Care Kit), working for the University of Cape Towns Lung Institute Knowledge Translation Unit, South Africa (UCT KTU), in partnership with the British Medical Journal (BMJ). She is based in London. Professional interests: Primary care, Public health, Global health, Health service management, Health IT, Health Knowledge management. Collaboration and partnership to enable and improve health services for the most needy in LMIC communities. She is a member of the HIFA Steering Group
Dear HIFA colleagues,
International guidelines from WHO and other international health agencies are of limited use if they are not adapted/translated into actual policy and practice at national and facility levels. To be maximally useful, such guidelines need to be developed and presented in formats that are easy to use and that take account the realities of low-resource settings.
I would like to highlight the recent message from Nanna Maaloe, Denmark/Tanzania. Personally I think what she has to say is very important and I reproduce it again in full below. I would especially like to highlight one comment that she makes:
“It is mind-boggling that the bulk of internationally-derived clinical guidelines targeting low-resource settings are published with little, if any, inputs from health workers at the grass root level, and often without pilot testing or post-implementation assessment.”
WHO Bulletin: Local adaption of intrapartum clinical guidelines, United Republic of Tanzania (2)
Dear Neil and others,
Thank you very much for sharing the PartoMa project at HIFA, and for the important points raised. We are of course eager to be a part of this discussion, and learn from the perspectives of HIFA’s members.
The PartoMa project’s bottom-up co-creation of clinical guidelines with birth attendants at Zanzibar’s tertiary hospital grew into a critical analysis of the applicability of leading international guidelines targeting maternity care in low-resource settings. Developing the PartoMa clinical guidance emphasized crucial obstacles for international maternal health guidelines to be easily adaptable to realities in maternity units carrying the highest burden of adverse outcomes. It was a time- and resource-consuming process that appeared unfeasible as a process to be conducted routinely within fragile health care systems, whether on national or facility level. Compared to international guidelines targeting maternity care in low-resource settings, alterations were necessary in frequency of clinical assessments, information load, ambiguity, and safety of treatment regimens.
It is mind-boggling that the bulk of internationally-derived clinical guidelines targeting low-resource settings are published with little, if any, inputs from health workers at the grass root level, and often without pilot testing or post-implementation assessment.
We acknowledge that improved clinical guidelines on the national levels are paramount– but do health ministries in low-income countries have the capacities to effectively adapt and modify international guidelines that are so unnecessarily far from realities in their countries? We are not intending to sidestep national guidelines, and we do call for research on alternative interactive steps to ensure that large-scale guidelines development targeting low-resource settings – on global, regional and national levels- is better attuned to inputs from the end-users, and thereby easier to adapt and use effectively. As Orem et al. found by reviewing 137 of Uganda’s health sector guidelines, lack of involvement of end users in the development process was a key contributor to ineffective, impractical, unclear, or too complex recommendations (Implement. Sci. 2012).
We agree that it is a crucial next step of the PartoMa project to see whether the PartoMa clinical guidelines from Zanzibar’s tertiary hospital can be modified and replicated at scale for improved health and survival at birth, and whether the process can serve as a model for other areas of health care. We are happy to share that we recently were granted 1.84 million USD from Danida, Ministry of Foreign Affairs of Denmark, to conduct larger implementation research. The key part of this will be to explore modifications needed and usefulness of the PartoMa intervention at five urban, mega maternity units in Dar es Salaam, Tanzania. This will of course include an analysis of related national guidelines in Tanzania mainland.
Please find more information on the PartoMa project at our website: publichealth.ku.dk/partoma/
On behalf of the PartoMa research team,
Nanna Maaloe, MD, PhD
The PartoMa Project
Nanna Maaloe, MD, PhD
University of Copenhagen
Global Health Section
Department of Public Health
& Copenhagen University Hospital, Hvidovre
Department of Gynecology and Obstetrics
HIFA Profile: Nanna Maaloe is a medical doctor and PhD fellow at the Global Health Section, University of Copenhagen & Mnazi Mmoja Hospital, Zanzibar, Tanzania and is based in Denmark. Professional interests: Obstetrics & Gynecology/childbirth care, development of clinical guidelines, health system research in low resource settings. Email: nannamaaloe AT outlook.com
Best wishes, Neil