Since 2014, the Knowledge Translation Unit, BMJ and Health Resources International West Africa (HRIWA) were in discussion with the World Bank, Oxford Policy Management and the Nigerian National Primary Health Care Development Agency (NPHCDA), to see how we can work together to improve the clinical competence of primary health care workers in Nigeria. Early in 2016 it was agreed that PACK Adult would be localised for use in Nigeria and that a training and implementation programme would be piloted across 36 primary health care facilities in Ondo, Adamawa and Nasarawa states.
From May to November 2016, the KTU worked with HRIWA team of clinicians led by Professor Joseph Ana to localise PACK Adult to Nigerian clinical protocols and practice. They focused on ensuring that the correct scope of practice, prescribing rights and referral levels were incorporated for all cadres of staff who deliver primary health care services in Nigeria: community health extension workers, community health officers, nurses, midwives and medical officers. In parallel, Professor Ana’s team worked with the KTU to localise the PACK training programme for pilot implementation. This preparation work was completed at the end of 2016.
Pilot training commenced in January 2017 with 4 Master Trainers per state trained to cascade training to 52 facility trainers. Each facility trainer facilitated end-user training onsite with staff, focusing initially on eight priority conditions: acute diarrhoea, pneumonia, diabetes mellitus type 2, pulmonary tuberculosis, malaria with anaemia, hypertension, pregnancy and fever. Fifty-one primary health care facilities participated in the pilot. The immediate evaluation took the form of a questionnaire to staff carried out at the beginning and end of the 6-month pilot period. This questionnaire evaluated clinical decision making and surveyed staff response to PACK and their views on its usefulness as a primary health care improvement tool. Focus group discussions were also conducted at the end of the pilot. An interactive PDF of PACK Nigeria Adult was uploaded on to tablets, introduced during the pilot and evaluated as well.
354 clinicians were trained to use the PACK Nigeria guide with substantial improvement seen in their clinical decision making after training and strongly positive user experience in terms of ease of use, improved ability to diagnose and manage patients and increased confidence as clinicians. Most clinicians preferred the digital version of the PACK Nigeria guide.
Following the completion of the pilot and evaluation, a decision was taken by the NPHCDA to introduce the PACK programme nationally, starting with other North-Eastern states. PACK Nigeria will also be included in the pilot of the Federal Ministry of Health Basic Health Care Provision Fund of the National Health Act 2014 in three more states and will see an expansion to include coverage of child care and integration into pre-service training curricula of all cadres of primary health care clinicians.
The PACK localisation to Nigeria and initial pilot is described further in PACK Collection paper - Awotiwon A, Sword C, Eastman T, et al. Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Nigeria. Submitted to BMJ Global Health as part of the PACK Collection 2018.