For the primary health worker in a low/middle-income country (LMIC) setting, delivering quality primary care is challenging. This is often complicated by clinical guidance that is out of date, inconsistent and informed by evidence from high-income countries that ignores LMIC resource constraints and burden of disease. The Knowledge Translation Unit (KTU) of the University of Cape Town Lung Institute has developed, implemented and evaluated a health systems intervention in South Africa, and localised it to Botswana, Nigeria, Ethiopia and Brazil, that simplifies and standardises the care delivered by primary health workers while strengthening the system in which they work. At the core of this intervention, called Practical Approach to Care Kit (PACK), is a clinical decision support tool, the PACK guide. This paper describes the development of the guide over an 18-year period and explains the design features that have addressed what the patient, the clinician and the health system need from clinical guidance, and have made it, in the words of a South African primary care nurse, ‘A tool for every day for every patient’. It describes the lessons learnt during the development process that the KTU now applies to further development, maintenance and in-country localisation of the guide: develop clinical decision support in context first, involve local stakeholders in all stages, leverage others’ evidence databases to remain up to date and ensure content development, updating and localisation articulate with implementation.

Nigeria, in its quest to strengthen its primary healthcare system, is faced with a number of challenges including a shortage of clinicians and skills. Methods are being sought to better equip primary healthcare clinicians for the clinical demands that they face. Using a mentorship model between developers in South Africa and Nigerian clinicians, the Practical Approach to Care Kit (PACK) for adult patients, a health systems strengthening programme, has been localised and piloted in 51 primary healthcare facilities in three Nigerian states. Lessons learnt from this experience include the value of this remote model of localisation for rapid localisation, the importance of early, continuous stakeholder engagement, the need expressed by Nigeria’s primary healthcare clinicians for clinical guidance that is user friendly and up-to-date, a preference for the tablet version of the PACK Adult guide over hard copies and the added value of WhatsApp groups to complement the programme of face-to-face continuous learning. Introduction of the PACK programme in Nigeria prompted uptake of evidence-informed recommendations within primary healthcare services.

The Federal Ministry of Health, Ethiopia, recognised the potential of the Practical Approach to Care Kit (PACK) programme to promote integrated, comprehensive and evidence-informed primary care as a means to achieving universal health coverage. Localisation of the PACK guide to become the ‘Ethiopian Primary Health Care Clinical Guidelines’ (PHCG) was spearheaded by a core team of Ethiopian policy and technical experts, mentored by the Knowledge Translation Unit, University of Cape Town. A research collaboration, ASSET (heAlth Systems StrEngThening in sub-Saharan Africa), has brought together policy-makers from the Ministry of Health and health systems researchers from Ethiopia (Addis Ababa University) and overseas partners for the PACK localisation process, and will develop, implement and evaluate health systems strengthening interventions needed for a successful scale-up of the Ethiopian PHCG. Localisation of PACK for Ethiopia included expanding the guide to include a wider range of infectious diseases and an expanded age range (from 5 to 15 years). Early feedback from front-line primary healthcare (PHC) workers is positive: the guide gives them greater confidence and is easy to understand and use. A training cascade has been initiated, with a view to implementing in 400 PHC facilities in phase 1, followed by scale-up to all 3724 health centres in Ethiopia during 2019. Monitoring and evaluation of the Ministry of Health implementation at scale will be complemented by indepth evaluation by ASSET in demonstration districts. Anticipated challenges include availability of essential medications and laboratory investigations and the need for additional training and supervisory support to deliver care for non-communicable diseases and mental health. The strong leadership from the Ministry of Health of Ethiopia combined with a productive collaboration with health systems research partners can help to ensure that Ethiopian PHCG achieves standardisation of clinical practice at the primary care level and quality healthcare for all.