Florianópolis, in Santa Catarina state,(1) was the first municipality in Brazil to achieve universal health coverage and has received awards for healthcare innovations.(2, 3) However, the quality of care between its clinics remains variable and barriers to access persist.(4) This led to a primary care reform in 2010, which targeted timely access to quality comprehensive care.(5) This reform prompted a search for primary care tools, including integrated clinical guidance, and the PACK programme was identified as potentially suitable.

A KTU mentor worked closely with an in-country team led by a local family physician to complete localisation of the PACK guide and associated training and implementation materials. The PACK Brasil Adulto -Versão Florianópolis guide was published in April 2016. It was the first PACK localisation to be completed using a mentorship model and PACK Global toolkit provided by the KTU (PACK Localisation Package)(6) and was completed almost exclusively remotely. A national version for Brazil was developed and made available later in 2016 through Senac, a Brazilian government publication and professional education institution.

Annual updates of both the PACK Brazil Florianópolis and national versions for 2017 and 2018 have been performed by the team in Florianópolis, assisted by the KTU, to reflect updated evidence, revised local policies and needs, and modifications prompted by user feedback. Electronic versions of each edition have also been made.

Florianópolis primary care health workers in PACK training

Florianopolis (Brazil) Primary care clinicians ready for PACK implementation

Training was delivered to 160 health workers in 24 clinics in Florianópolis. Although delayed by municipal strike action in some clinics, training coverage is high, with 100% of eligible health workers exposed to at least one training session, and 70% completing all training sessions. The effectiveness of the PACK training approach on patient care and outcomes (specifically diabetes, cardiovascular and respiratory endpoints) is being compared to passive dissemination of the PACK guide in a randomised evaluation.(7) Outcomes are currently being analysed. A process evaluation involving PACK trainers, trained health workers and local PACK programme leads, assessing the acceptability, feasibility and uptake of the programme among primary care practitioners is also ongoing. Preliminary findings suggest a positive response to the PACK programme.

The PACK programme continues to form part of primary care in Florianópolis and results from the process evaluation and trial will provide a greater understanding of its effectiveness. There are ongoing discussions at federal, state and municipal levels as well as with various non-governmental organisations and private healthcare providers in the hope of actualising broader scale up of the PACK programme across Brazil. A paper detailing the localisation of the PACK programme to the Florianópolis primary health care context and highlighting the learnings from the experience forms part of a PACK Collection of papers in the BMJ Global Health journal.(8)


PACK Florianopolis Adult: symptom contents

PACK Florianopolis Adult: chronic conditions contents

Page references
  1. Estimativas Da População Residente No Brasil E Unidades Da Federação Com Data De Referência Em 1º De Julho De 2017 (Available from: accessed September 2018.
  2. da Cruz AM, Oliveira MIR. Estudo para Redimensionamento de Auxiliares Administrativos nas Unidades Básicas de Saúde da Secretaria Municipal. Prêmio Inovasus 2013:81.
  3. Saraiva S, Cremonese E. Implantação do modelo de apoio matricial em saúde mental no município de Florianópolis, SC III Concurso nacional de experiências em saúde da família: trabalhos premiados Brasília: Brasil Ministério da Saúde 2008
  4. Giovanella L, Mendonça M, Almeida PFd, et al. Family health: limits and possibilities for an integral primary healthcare approach in Brazil. Cien Saude Colet 2009;14(3):783-94.
  5. Prefeitura Municipal De Florianópolis Secretaria Municipal De Saúde Gabinete Do Secretário (Available from: accessed September 2018.
  6. Fairall L. Serendipity and scaling up towards universal primary care: The BMJ Opinion, 2016.
  7. Bachmann MO, Bateman ED, Stelmach R, et al. Integrating primary care of chronic respiratory disease, cardiovascular disease and diabetes in Brazil: Practical Approach to Care Kit (PACK Brazil): study protocol for randomised controlled trials. Journal of Thoracic Disease 2018;3(2)
  8. Wattrus C, Zepeda J, Cornick R, et al. Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Brazil. Accepted for publication by BMJ Global Health as part of PACK Collection Manuscript ID bmjgh-2018-001016 2018