ADSPHCDA and PACK Nigeria Meeting for Scale up of PACK in Adamawa State

Notes from PACK Nigeria Meeting in Adamawa 3rd August 2017
ADSPHCDA has been impressed by the acceptability of PACK Nigeria guide in the field and its ease of use (especially ePACK Nigeria) and impact on diagnosis and treatment. ADSPHCDA has also noticed a reduction in polypharmacy with PACK Nigeria. This has been particularly visible with the elimination of antibiotics from malaria prescriptions in Fufore LGA.

MTs have noticed that some facility staff have encountered some language issues (e.g. lethargy – also a problem in the ALMANACH IMCI protocol). Attahiru will document the known issues and share the list with HRIWA so that revisions can be considered for PACK Nigeria 2018. They have also found that the battery of the ePACK Samsung tablets can last for as little as 3 hours when in constant use, which requires the use of two tablets to complete a single shift. We discussed the potential for battery packs to help address this issue.

The Secretary at Fufore LGA was full of praise for PACK, saying that “PACK has raised clinical competence” and “PACK has improved professionalism tremendously”.

Dr Belel, Chairman ADSPHCDA, described PACK Nigeria as a “high-impact intervention” and a “one-stop shop for OPD”. He would like to start scaling up the current version of PACK Nigeria Adult across the state at the earliest opportunity rather than wait for PACK Child and the revised PACK Adult 2018 to be available in June 2018. Any scale-up plan must include an evaluation of PACK’s impact and a baseline must be established before scale-up can begin. ADSPHCDA will give some thought to priority metrics and the measurement tools available to them. Examples of metrics might include: number of RDT lab tests requested, % of patients receiving antibiotics, HRH availability, polypharmacy (number of drugs and class of drugs), facility readiness (equipment, tests, drugs), use of protocols / guidelines before introduction of PACK Nigeria, etc. HRIWA will review baseline ideas with ADSPHCDA during the final PACK pilot visit at the end of August.

Dr Belel is keen to include ePACK in the scale-up at the appropriate time and is keen to explore the possibility of receiving data from an enhanced PACK app, much as they currently do with their ALMANACH IMCI app. They can share examples of the summary sheets for their HMIS. He has offered to share BMJ’s concept paper with CHAI, who he thinks might be open to the idea of funding development of such an app.

ADSPHCDA is already preparing the 2018 budget now and is in discussion with UNICEF and the EU. The cost of scaling up PACK Nigeria must be included in this budget. BMJ and HRI would be very happy to help with any advocacy kits for UNICEF and the EU.

Scaling up PACK Nigeria in Adamawa
ADSPHCDA has already given considerable thought to how they would like to scale up PACK Nigeria and ensure local ownership and supervision.

We have agreed the following set of assumptions upon which we can base a costed plan for scale-up:

  • 403 PHCs across the state
  • An average of 4 or 5 clinicians per PHC (so up to 2,000 clinicians in total)
  • 21 LGAs
  • 4 new Master Trainers for each of the 3 senatorial zones (12 in total)
  • ISS team at each LGA will be responsible for supervision of PACK training during their monthly visits to each PHC (instead of the NSHIP verifiers)
  • 2 supervisors per LGA (one focal person at the LGA headquarters and one member of the ISS team) will participate in the first 3 days of FT training
  • The 2 supervisors will cascade PACK Nigeria to the rest of the LGA ISS team.

BMJ/HRI’s current training and supervision assumptions for immediate scale-up:

  • One 4-day Master Trainer training workshop, led by HRIWA with support from existing ADSPHCDA MTs, to be held at the ADSPHCDA office in Yola, potentially in October 2017 (final date TBC)
  • Key state-level stakeholders (e.g. local CHPRB, MNC representatives, Associations, tutors from Schools of Health Technology) to attend MT training on manager’s day
  • 2 week break before FT training so that the new MTs can familiarise themselves with PACK
  • First 4-day FT training workshops to be held simultaneously in each of the 3 senatorial zones (one of which will be Yola)
  • First FT training workshops to be led by the 4 new MTs and supported by 1 existing MT from ADSPHCDA and 1 member of HRIWA team
  • Each new MT will then be accompanied by 1 ADSPHCDA MT or 1 HRIWA to support their first plenary at the PHC level
  • Subsequent FT training workshops (one per LGA and at a pace to be determined by ADSPHCDA) will be led by new MTs without additional support
  • Key LGA stakeholders to attend FT training on manager’s day
  • HRIWA will provide sufficient training materials to support cascade of training from 12 Master Trainers to 403 Facility Trainers
  • HRIWA will provide sufficient hard copies of the PACK Nigeria Adult guide (subject to confirmation by ADSPHCDA of the number required)
  • ISS teams will be encouraged to set up a WhatsApp group for their LGA PHCs (this need not be restricted to PACK Nigeria)
  • ISS teams will then be added to the existing PACK Adamawa WhatsApp group
  • HRIWA will travel to Adamawa one month after the first FT training workshops for review/mentoring, then two months later and finally two months after that
  • HRIWA will hold a subsequent 4-day MT workshop (potentially in July 2018) to support the introduction of PACK Nigeria Child and PACK Nigeria Adult 2018.

Summary of actions

  • ADSPHCDA to confirm total number of clinicians requiring PACK Nigeria guide in 2018, split by hard copy and ePACK (BMJ will make assumptions in the meantime)
  • BMJ to provide indicative costs for immediate scale-up of PACK Nigeria Adult guide by 11/08
  • ADSPHCDA to confirm what support, if any, they require from BMJ and HRI to engage with UNICEF and EU
  • ADSPHCDA to send HRIWA by the end of August examples of any language issues in the PACK Nigeria guide so that revisions can be considered for PACK Nigeria 2018
  • ADSPHCDA to provide summary sheets for HMIS
  • ADSPHCDA to check existing NSHIP metrics to quantify any reduction in prescription of antibiotics in Fufore LGA since the start of the pilot
  • ADSPHCDA to identify priority metrics and the measurement tools available by the end of August
  • HRI to review metrics with ADSPHCDA during pilot visit at the end of August
  • HRI and ADSPHCDA to agree dates for Master Trainer training at the end of August.