Strengthening the quality of paediatric primary care: A process evaluation of a complex health systems intervention in South Africa

BACKGROUND: Innovative strategies like WHO’s Integrated Management of Childhood Illness (IMCI) have resulted in progress in addressing infant and child mortality. However, the needs of children continue to present a burden upon primary healthcare services. The capacity of services and quality of care offered require greater support to address these needs and extend integrated curative and preventive care, specifically, for the well child, the child with a long-term health condition and the child older than 5 years, not included in IMCI. In response to these needs, the PACK Child intervention was developed, based on a similar successful approach in adults, that expands the scope and reach of integrated management and training programmes for paediatric primary care. We report findings from the process evaluation of the integration of PACK Child intervention within the existing primary health care system. METHODS: A mixed methods process evaluation was completed in ten primary health care facilities in the Western Cape province in South Africa, where clinicians were trained to integrate PACK Child into routine practice. Qualitative data included interviews with managers, clinicians, caregivers and policymakers; observations of training, consultations and clinic flow. Quantitative data included training logs and clinicians’ questionnaires. RESULTS: Impact of PACK Child on clinical practice: Longer consultations, improved clinical knowledge and practice, better teamwork, strengthening of appropriate referrals and inclusion of psychosocial risk screening. Implementation fidelity of PACK Child was hindered by over-reliance on documentation and embedded checklist approach to consultations limited to acute episodic illnesses. PACK Child increased caregiver participation during consultations. CONCLUSIONS: The PACK Child intervention has strengthened primary care for children despite institutionalised care provided by a limited number of clinicians focusing on acute illness with little participation of the caregiver. With refinement of the programme, there is potential for PACK Child to strengthen paediatric care in low-resource settings.