Integrated clinical management tools for respiratory diseases: lessons from PAL in sub Saharan Africa.
THE URGENT NEED to address chronic diseases in developing nations is at last being recognised at all levels, from the United Nations to frontline clinicians, and calls are being made for health system reforms and methods to address this need.1 The situation is more complex in sub Saharan Africa, where the demands of tuberculosis (TB) and human immunodeficiency virus (HIV) infection eclipse those of chronic diseases, and in many countries scant provision is made for diagnosing and treating even the most prevalent of these. The Practical Approach to Lung Health (PAL) approach, developed by the Stop TB Partnership, is an innovative method for achieving the dual goals of improving the case detection of TB and diagnosing and treating priority lung diseases.2 Although PAL has been adapted and piloted in approximately 40 countries, few have embedded PAL within their health systems. Experience with PAL in sub Saharan Africa, with its special challenges of TB and HIV, is limited. Since 2001, our group in Cape Town, South Africa, has been involved in the adaptation of PAL in South Africa, Malawi and Botswana. Early experience confirmed satisfaction and uptake by clinicians, but they requested that the integrated algorithmic diagnostic and management approach be expanded to cover other conditions commonly seen in primary care. Thus PALSA became PALSA PLUS, then Primary Care 101 (PC101) and finally, in 2016, the Practical Approach to Care Kit (PACK).3 Integral to PALSA and all subsequent versions have been two other elements: 1) a continuing education approach based on adult learning theory, a case based interactive training curriculum presented in regular short on site sessions with a facility trainer; and 2) research evaluations of the performance of each major new version. PC101 has been adopted by the South African National Department of Health, and is being scaled up in all state primary care clinics and included in the curriculae of nursing colleges and medical schools. It is updated annually to ensure compliance with changing treatment policies. Over the past decade, tens of thousands of primary care nurses have been trained and primary care clinicians receive a copy of each current version. In this issue of the Journal, Banda and colleagues present a systematic review of PAL in sub Saharan Africa based entirely on this experience in South Africa and Malawi.4 They correctly conclude that studies are sparse, that PAL appears to be effective in improving the diagnosis and treatment of patients with TB, and that evidence of benefit for other respiratory diseases is more limited and requires further study. This conclusion is understandable, given the limitations of the methodology used in systematic reviews, but is inadequate as a description of the PAL approach, for several reasons. First, process outcomes for TB (and other single diseases) do not reflect the overall benefit achieved with a complex intervention such as PAL, where many small improvements may represent a substantial advantage, particularly if introduced without 'harm' The word 'pragmatic' does not appear in their manuscript, but, being a complex intervention in a usual care setting, with all the limitations associated with such trials, this qualification is important. Another explicit objective of the PAL approach is to empower, motivate and equip primary care clinicians. Qualitative research contained in papers excluded from the current analysis contain important findings that may explain the rapid enthusiastic uptake of PALSA by endusers and health authorities.5 End user satisfaction is arguably a more relevant and sensitive predictor of the sustainability of an innovation. A further significant omission in the meta analysis is failure to define 'usual treatment' In the studies cited, this involved control clinics receiving the clinical management tool without the training component. Thus, it was the package of tool plus training versus the tool alone that was investigated. The emphasis in training is on the carer and the quality of care they deliver, rather than the tool, empowering overstressed clinicians required to handle a wide range of conditions quickly and consistently, in accordance with evidence supported policies. A coherent and current treatment algorithm provides support. Although there are gaps in the evidence base supporting the use of PAL in sub Saharan Africa, there are few alternatives, and in many countries in the region little or no provision is made for chronic lung diseases. The example of PAL in South Africa should be used to engage and urge health departments to provide for these conditions.
The international journal of tuberculosis and lung disease the official journal of the International Union against Tuberculosis and Lung Disease