Making Global Strides In Primary Care

For the past two decades, UEA’s Prof Max Bachmann and colleagues at the University of Cape Town have been improving primary care in South Africa, saving lives in the process. Now they’ve brought their transformative healthcare interventions six new countries, from Ethiopia to Brazil.

Since 2000, UEA researchers Prof Max Bachmann, Prof Garry Barton and Dr Jamie Murdoch have worked with the University of Cape Town’s Knowledge Translation Unit (KTU) to show that educational interventions developed by KTU are improving primary health care in low- and middle-income countries.

Chronic diseases such as tuberculosis, HIV, asthma, diabetes, and hypertension are common in developing countries, but are often undetected as frontline health workers lack the clinical skills required to make an accurate diagnosis. Trials by the UEA researchers in Africa and Brazil have demonstrated that clinical decision tools and healthcare worker training can significantly improve patients’ health and care, and ease the burden on support systems.

The journey started in 2000 with the development of the PALSA (Practical Approach to Lung Health in South Africa) clinical guidelines. By 2005 these guidelines had increased diagnosis of tuberculosis by 72%, asthma by 90% and emergency referrals by 159%. PALSA PLUS built on this work and included new guidelines on HIV, AIDS, and other sexually transmitted diseases. This in turn was followed by Primary Care 101 which incorporated diabetes, hypertension, and depression, with equally impressive trial results.

With such success in healthcare settings in South Africa, KTU and the UEA team developed a catch-all approach and started to look further afield. Which other developing countries could benefit from such a pioneering programme?

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Ongoing impact of PACK in South Africa

PACK, the Practical Approach to Care Kit, is the solution, integrating all four interventions.

PACK Adult (also known Adult Primary Care – APC) covers the most common and critical adult health conditions. Four South African nursing schools and three medical schools have added PACK to their undergraduate curricula since 2014 and, when in 2015 the South African National Department of Health launched its Ideal Clinic programme, it used PACK and APC as the basis, aiming to integrate and strengthen chronic disease management in all 3,500 primary care clinics in the country. These clinics are the main source of healthcare for 50 million South Africans living without health insurance.

The impact is huge. Almost everyone currently receiving ART in South Africa would eventually die of AIDS without it"

Prof Bachmann’s findings also enabled nationwide expansion of antiretroviral treatment for HIV based on STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV), a package of guidelines and training enabling nurses to prescribe antiretroviral treatment. In 2021, the UEA team’s randomised trial of 15,500 patients with HIV showed that nurse-led antiretroviral treatment (ART), supported by STRETCH, improved patients’ health – and was safe. A parallel economic evaluation showed that STRETCH was also cost-effective and affordable, and today ART continues to expand in South Africa, reaching 5.6 million people by 2020.

The impact is huge. Almost everyone currently receiving ART in South Africa would eventually die of AIDS without it but, instead, ART has reduce mortality by 86% in people who receive it. Having over 5.6 million on ART means that almost five million lives would be saved. And, what’s more, tuberculosis incidence in South Africa has decreased by about 177,000 cases per year from 2014 to 2019, primarily due to ART expansion.

Impact of PACK in Brazil, Nigeria, and Ethiopia

PACK has proved so successful in South Africa that KTU has now adapted it for an international audience. PACK Global Adult is adapted for each country and updated each year using the latest evidence about accurate diagnosis and effective treatment. By 2020 it had been rolled out in six countries, delivered through a comprehensive localisation package which includes a PACK adult guide, training methods, health system strengthening initiatives, and monitoring and evaluation. So far 185,000 guides had been distributed and 30,000 health workers trained.

In Ethiopia, 100 master trainers from the Ethiopian Ministry of Health were trained to train frontline primary care workers in every primary care facility in the nine regions of the country while elsewhere in Africa PACK Adult was implemented in 52 clinics in three Nigerian states between 2016-18. Meanwhile, and on the opposite side of the Atlantic a PACK Adult trial was being rolled out in the Brazilian city of Florianopolis, before being extended to cover the entire city of 480,000 residents. Expansion to the rest of Brazil is currently being negotiated.

Impact on future generations

Ever evolving, PACK Child incorporates the principles applied to PACK Adult and is designed to equip doctors and nurses with the skillset required to diagnose common childhood conditions from birth to 13 years of age. Piloted in ten South African clinics, their evaluation of PACK Child identified obstacles to implementation that needed addressing before it can be rolled out across South Africa. PACK Adolescent, a UK-MRC-funding programme which UEA and KTU are working on, will complete the set and extend PACK’s reach from health services to schools. And the work doesn’t stop there.

Work with KTU on a four-year programme over two provinces of South Africa – Western Cape and KwaZulu Natal – called ENHANCE has also begun. This will deliver an adaptation of PACK Adult to focus on those with multiple long-term conditions. The team is also working with KTU, the University of KwaZulu Natal, and King’s College London on ASSET, an NIHR-funded programme on health system strengthening in Southern Africa. This programme was originally aimed to improve diagnosis and care of tuberculosis in South Africa, but has expanded during the pandemic to cover COVID-19 and health worker wellbeing.

Prof Bachmann is working with UK and East African researchers and health ministries, on a randomised trial exploring the upscaling of integrated primary care for HIV, diabetes and hypertension in Uganda and Tanzania. He is also working with the researchers from Harvard University and the University of KwaZulu Natal on initiatives to improve control of high blood pressure, using home-based blood pressure monitoring and outreach to patients’ homes by community health workers.

All of these efforts have the same aim: to ensure that people in resource limited settings can get the affordable high quality health care that they need. Overall, the health implications of these interventions and programmes on African and Brazilian populations is huge.