There is an urgent need to depart from in-service training that relies on distance and/or intensive off-site training leading to limited staff coverage at clinical sites. This traditional approach fails to meet the challenge of improving clinical practice, especially in low-income and middle-income countries.

South Africa’s University of Cape Town Lung Institute Knowledge Translation Unit has developed a facility-based training strategy for implementation of its Practical Approach to Care Kit (PACK) primary care programme.

The training has been taken to scale in primary care facilities throughout South Africa and has shown improvements in quality of care indicators and health outcomes along with end-user satisfaction.

PACK training uses a unique approach to address the needs of frontline health workers and the health system by embedding a health intervention into everyday clinical practice at the facility level.

This paper describes the features of the PACK training strategy: PACK training is scaled up using a cascade model of training using educational outreach to deliver PACK to clinical teams in their health facilities, in short, regular sessions.

Drawing on adult education principles, PACK training empowers clinicians by using experiential and interactive learning methodologies to draw on existing clinical knowledge and experience. Learning is alternated with practice to improve the likelihood of embedding the programme into everyday clinical care delivery.

Educational outreach training

Educational outreach is a strategy shown to be effective in changing health worker behavior and practice, particularly prescribing. LMIC-setting primary care studies of educational outreach have demonstrated improvements across a range of morbidities including childhood infections and asthma.

The PACK educational outreach training comprises regular (every 1 to 2 weeks), short (1 to 2 hours) sessions that occur onsite and in-service at the primary care facility.

The sessions are incorporated into the working day and as they are onsite, allow for the alternation of learning with practice. Being onsite also limits disruption of clinical services while learning continues at the facility.

The core aim of the training is to ensure that health workers mainly doctors and nurses understand how to use the PACK guide and become accustomed to referring to it in their everyday clinical practice and communication.

However, it also provides the opportunity for another cadre of staff to participate in the training to identify and address as a team health systems issues raised by using the PACK guide, including patient flow in the facility, referral pathways or medication supply.

Health systems strengthening is integrated and embedded in the content of the training, offering multiple opportunities for discussions on facility-level health systems strengthening.