Prompted by numerous requests from managers, PALSA PLUS trainers and nurses, who liked the simplicity of the guideline and training approach and indicated an urgent need for an equivalent for other diseases common in primary health care, the KTU started work in 2006 on an expansion of the PALSA PLUS programme to include all priority chronic diseases. The guideline has been expanded to address 40 common presenting symptoms and 20 chronic conditions in adults, all in 101 pages. It retains many aspects of PALSA PLUS, including the symptom-based approach and the standardised format for routine care of a chronic condition.

Chronic conditions covered by the guideline include:

• Chronic diseases of lifestyle (hypertension, diabetes, cardiovascular risk and disease)
• Infectious diseases (TB, HIV, STIs)
• Chronic respiratory diseases (asthma, COPD)
• Mental health conditions (depression, anxiety, substance abuse)
• Women’s Health (antenatal care, contraception)
• Others (musculoskeletal conditions, epilepsy, skin conditions)

Expansion and local adaptation followed a consultative process. National and international (including WHO) guidelines and the evidence were reviewed, summarised and discussed by special interest working groups comprising tertiary level experts, primary care physicians and nurses, patient advocates and managers. The South African 2008 Essential Drug List and Standard Treatment Guidelines are integral in the content. In addition, consistency with provincial prescribing provisions is key and has been addressed in the Western Cape in consultation with representatives from the provincial Pharmacy and Therapeutics Committee, Nursing Directorate and other relevant role players. To view the list of over 150 contributors to the Primary Care 101 guideline, click here.

Formative research involved testing by end-users, including doctors, nurses and managers and led to refinement of the guideline. In 2010, the KTU received funding from the Chronic Disease Cluster at the National Department of Health to complete development process. In May 2011, Primary Care 101 was launched as part of a pragmatic randomised controlled trial (RCT) in the Eden district of the Western Cape. 6 PALSA PLUS trainers were trained to facilitate on-site sessions in intervention primary care facilities, and 150 sessions later, this on-site training has now been completed.

The KTU is also a co-applicant on a National Institute of Heart, Lung and Blood Institute (NHLBI) grant, which supported the establishment of a centre for chronic diseases at the University of Cape Town (Chronic Disease Initiative in Africa - CDIA). The NHLBI funding is restricted to the development of research capacity and has funded the RCT which began in March 2011 to evaluate the Primary Care 101 guideline training programme. 38 Clinics were randomised into two groups: an intervention group which received the programme, and a control group which continued with usual care (including PALSA PLUS). A total of 4500 patients were interviewed at baseline between March and December 2011. Patients will be interviewed once more, 14 months after their first interview. These interviews are expected to be completed by December 2012. Outcomes measured are the improvement in and cost effectiveness of care for patients with diabetes, hypertension and chronic respiratory disease and in the detection of depression. Expanded prescribing provisions for professional nurses trained in Primary Care 101 were approved by the Pharmaceutical and Therapeutics Committee of the Western Cape for the purpose of the trial. The expanded prescribing provisions include enalapril and amlodipine for hypertension, sulphonylureas for diabetes, simvastatin for managing cardiovascular risk, budesonide for asthma and short course oral prednisone for exacerbations of asthma and COPD. We also hope to run a qualitative process evaluation that will complement and augment the trial.

The KTU has updated and revised the Primary Care 101 guideline for national use, following input from the Colleges of Medicine of South Africa, the Medicines Control Council, the South African Pharmacy Council, the South African Nursing Council and the National Department of Health Chronic Disease Cluster. A pilot of the programme commenced in 3 districts in North West, Mpumalanga and Gauteng Provinces in May 2012.