Table 2 Macro-contextual features of paediatric primary care in Western Cape, South Africa

Integrated Management of Childhood Illness (IMCI) [9]

World Health Organisation’s IMCI is an integrated strategy that is targeted at reducing death, illness and disability, and promoting growth and development for children 0–5 years old. This strategy comprises both preventive and curative elements and has three components targeted at improving skills of primary care clinicians, health systems functioning, and family and community health practices. Principally delivered by nurses, IMCI is underpinned by a risk minimisation approach with the main aim of a provider-patient contact to ensure all children with danger signs are referred to the next level of care and provide reassurance that growth monitoring (and associated interventions e.g. Vitamin A) and immunisation take place.

IMCI was introduced in South Africa in 1996 with a primary implementation focus on training and capacity building of clinicians [17]. In the Western Cape, the main manifestations of IMCI are the chart booklet, last updated in 2014, a training programme that targets professional nurses with the intention that they then see children, and the IMCI checklist (Additional file 2).

Primary Health Care Standard Treatment Guidelines (STG) and Essential Drug List (EDL) [43]

National level guidance comprising evidence based standardised recommendations for healthcare workers, in order to promote equitable access to safe, effective, and affordable health medications. These guidelines are not specific to children and include adults. There is limited guidance for neonates. Medication for children is recommended according to weight bands.

Expanded Programme on Immunization (EPI SA) [44]

Vaccination schedule updated in December 2015, implemented in provincial and municipal clinics, reducing in frequency after 18 months old up to 12 years. (https://www.westerncape.gov.za/assets/departments/health/vaccinators_manual_2016.pdf)

First 1000 Days Initiative [38]

The first 1000 days initiative aims to improve the nutrition of mothers and children during the first 1000-day window to ensure children get the best start to life and the opportunity to reach their full potential, starting from conception, moving through pregnancy, birth, and after the first 2 years of life (https://www.westerncape.gov.za/first-1000-days/).

Nurturing Care Framework [39]

The Nurturing Care Framework provides a roadmap for how early childhood development unfolds and how it can be improved by policies and interventions. It outlines: why efforts to improve health, well-being and human capital must begin in the earliest years, from pregnancy to age 3; the major threats to early childhood development; how nurturing care protects young children from the worst effects of adversity and promotes development – physical, emotional, social and cognitive; and what caregivers need in order to provide nurturing care for young children. (https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf).

Nurse restrictions on prescribing

IMCI-trained nurses treating children are typically professional nurses with prescribing limited to treating acute symptoms only. Restrictions are in place for medications used to manage long-term conditions including inhaled corticosteroids for asthma and topical steroids for eczema. This results in referrals, with additional waiting time and contact, to clinical nurse practitioners or doctors for prescriptions to treat chronic conditions.

They need to treat their client according to their scope of practice. They can only prescribe according to a schedule, in fact according to the national EDL [Essential Drugs List], where it says for this condition you can only give a certain treatment. (Manager interview, Phase 1)

Chronic Illness Management and training for over 5 s

Nurses lack experience with chronic illness management at primary care level.

“I: How often do you come back for the asthma medication?

CG: They didn’t put her on medication. They just said that I must see...look after. I must just keep an eye that her chest doesn’t tighten. I must bring her back immediately once this happens, or take her to the hospital, but they gave her an inhaler.” (Caregiver interview, Phase 2)

No specific guidelines or stationery for children above 5, until introduction of Integrated Clinical Stationery (Western Cape only – see below)

“Our clinical notes for the child older than 5 years we only use our clinical notes to make an entry we don’t have a form like this for children older than 5 years.”

(Manager interview, Phase 2)

Road to Health Booklet (RtHB) [35]

RtHB provided as patient medical record (Additional file 4), widely implemented in PHC facilities throughout South Africa. Underpinned by philosophy to support well child routine visits, continuity of information and provide a hand held record for caregivers that summarises the child’s health in the first 5 years of life. The RtHB was substantially revised and expanded to include health promotion messages in February 2018 (https://www.westerncape.gov.za/general-publication/new-road-health-booklet-side-side-road-health).

Integrated Clinical Stationery (ICS)

ICS was developed by the Western Cape Department of Health in 2015 following identification of a gap in clinical recordkeeping for children during a pilot audit in facilities. Facility records for routine care were found to be inadequate and IMCI checklists were scattered in patient’s folders in no particular order. ICS was designed to meet the need for facility and visit-based stationery that integrated well and sick child care. The stationery (Additional file 3) was piloted in five facilities from July 2016 and implemented in half of PACK Child pilot facilities at the time of this study. It has since been adopted for province-wide implementation.

Patient co-payments

In South Africa primary care is free at point-of-care including access to a wide range of medications and investigations for people of all ages. Hospital-level care is free for all pregnant women and children under 5.