Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child)

Background Despite significant reductions in mortality, preventable and treatable conditions remain leading causes of death and illness in children in South Africa. The PACK Child intervention, comprising clinical decision support tool (guide), training strategy and health systems strengthening components, was developed to expand on WHO’s Integrated Management of Childhood Illness programme, extending care of children under 5 years to those aged 0–13 years, those with chronic conditions needing regular follow-up, integration of curative and preventive measures and routine care of the well child. In 2017–2018, PACK Child was piloted in 10 primary healthcare facilities in the Western Cape Province. Here we report findings from an investigation into the contextual features of South African primary care that shaped how clinicians delivered the PACK Child intervention within clinical consultations. Methods Process evaluation using linguistic ethnographic methodology which provides analytical tools for investigating human behaviour, and the shifting meaning of talk and text within context. Methods included semi-structured interviews, focus groups, ethnographic observation, audio-recorded consultations and documentary analysis. Analysis focused on how mapped contextual features structured clinician-caregiver interactions. Results Primary healthcare facilities demonstrated an institutionalised orientation to minimising risk upheld by provincial documentation, providing curative episodic care to children presenting with acute symptoms, and preventive care including immunisations, feeding and growth monitoring, all in children 5 years or younger. Children with chronic illnesses such as asthma rarely receive routine care. These contextual features constrained the ability of clinicians to use the PACK Child guide to facilitate diagnosis of long-term conditions, elicit and manage psychosocial issues, and navigate use of the guide alongside provincial documentation. Conclusion Our findings provide evidence that PACK Child is catalysing a transition to an approach that strikes a balance between assessing and minimising risk on the day of acute presentation and a larger remit of care for children over time. However, optimising success of the intervention requires reviewing priorities for paediatric care which will facilitate enhanced skills, knowledge and deployment of clinical staff to better address acute illnesses and long-term health conditions of children of all ages, as well as complex psychosocial issues surrounding the child.

approach that strikes a balance between assessing and minimising risk on the day of acute presentation and a larger remit of care for children over time. However, optimising success of the intervention requires reviewing priorities for paediatric care which will facilitate enhanced skills, knowledge and deployment of clinical staff to better address acute illnesses and long-term health conditions of children of all ages, as well as complex psychosocial issues surrounding the child.

Background
The three principal objectives of the 2016-2030 Global Strategy for Women's, Children's and Adolescents' Health are Survive, Thrive and Transform, including the need to build resilience in health systems, improve the quality of health services and equity in their coverage [1]. These objectives align with the United Nation's Sustainable Development Goals [2], which envisage the highest standards of physical and mental well-being for these vulnerable groups. However, large inequalities persist in access to and the quality of care in many low and middle-income countries (LMICs) [3]. In South Africa, the management of common childhood illnesses at a primary healthcare level remains poor with preventable and treatable conditions, particularly pneumonia and diarrhoea, remaining the leading causes of death in children under five [4]. With under-five mortality rate of 42 per 1000 live births in 2015 [4], considerable ongoing improvements in health worker skills and quality of care are required to reach the Sustainable Development Goal target of less than 25 per 1000 live births by 2030.
Trends in the global burden of disease from 1990 to 2015 show increased rates of chronic NCDs across LMICs both for children aged below and above five years [5], calling for interventions that more effectively identify and treat common chronic conditions, for example asthma which globally is the most common long-term health condition in childhood. In South Africa, the prevalence of asthma is 10% in [6][7] year olds and as high as 15% in [13][14] year olds, and approximately half of affected children have severe uncontrolled symptoms and more than 30% have never been formally diagnosed [6]. Lack of chronic illness management training for nurses and limited access to doctors and equipment in primary health care facilities contribute to this situation, often leading to children with long term conditions bypassing these clinics and presenting at secondary level hospitals [7,8].
The World Health Organizations' (WHO) Integrated Management of Childhood Illness strategy (IMCI) [9], was developed to address the top causes of mortality in children under five, and is the standard of care in over 100 Low-and Middle-Income Countries (LMICs), including South Africa [10]. A 2010 multi-country review of IMCI [11] confirmed improvements in prescription accuracy, treatment and health service quality and a 2016 Cochrane review [12] found evidence of a reduction in neonatal and infant mortality.
However, an evaluation of IMCI's impact since its introduction in 1998 reported variable fidelity to the strategy's guidance [13] limited training and ongoing supervision of primary care workers, (in South Africa usually professional nurses), and infrequent updating [14].
The IMCI strategy also does not address the health needs of children over five years or those with chronic conditions needing regular follow-up, and requires more complete integration of curative and preventive measures, including care for the well child. A key conclusion of WHO's 2016 strategic review of IMCI stated that "with attention focused on specific child health areas such as immunization and communicable diseases, a holistic view of child health has arguably been lost inside the continuum of reproductive, maternal, newborn, child and adolescent health." [12,15] In the Western Cape province of South Africa almost every public sector primary care facility employs an IMCI-trained nurse, and it is these nurses who attend to the majority of children's healthcare care needs. At a series of meetings with key stakeholders in provincial paediatric health -primary care nurses, doctors, managers and educators, hospital-level paediatricians and policy makers -the growing gaps in knowledge and expertise for children at primary care level were recognised as well as a need to integrate well child routine care into the delivery of everyday paediatric primary care.
To help address these gaps, the Knowledge Translation Unit (KTU) in Cape Town, South Africa developed a paediatric version of its Practical Approach to Care Kit, (PACK) [16], intervention, comprising of a clinical decision support tool, training programme, and health system strengthening including enhanced supervision with regular updates as guidance and policies change [17][18][19][20]. PACK Child incorporates IMCI content but provides extended clinical guidance for the child older than 5 years (up to age 13), 16 long-term health conditions, an approach to the well child and additional non-life-threatening, yet common conditions. The implementation and training elements of PACK Child are modelled on and complement PACK Adult [18], which was trialled and scaled up in South Africa to over 30 000 clinicians in more than 3500 clinics [21][22][23], using a systematic, educational outreach training strategy and cascade model of implementation [19]. PACK is also being implemented in Botswana [24], Brazil [25], Nigeria [26] and Ethiopia [27], is available globally through a partnership with BMJ (pack.bmj.com) and is being localised for piloting in China [17].
Implementation of a more expanded programme like PACK Child alongside the longestablished IMCI raised many legitimate concerns for policymakers, prompting a detailed process evaluation of the first pilot of the intervention in the Western Cape Province.
These concerns were chiefly around whether, given the structural constraints, it was feasible to extend the scope of paediatric primary care delivery, and whether PACK Child would augment or undermine other priorities like IMCI, early childhood development, growth monitoring and preventive care and appropriate referral patterns.
In this article, we report on how the organisational and social context of paediatric primary care influenced implementation of PACK Child, presenting findings from an indepth qualitative analysis of audio-recorded consultations to demonstrate the relationship between the delivery of PACK Child and the wider social context of paediatric primary care.
Previous research that has observed clinical consultations in LMICs has relied heavily on structured checklists to assess clinician's adherence to clinical protocols, and in paediatric consultations the focus has been on clinician adherence to IMCI guidelines [28,29]. Whilst raising awareness of the extent of IMCI implementation, such research has isolated individual clinician performance from the contextual conditions that facilitate or constrain their behaviour, thereby offering limited insight into how to improve delivery of care. In the study reported here, we attempted to move beyond individualised explanations of clinician performance by tracing a relationship between the South African healthcare system, clinician-caregiver interactions and clinician's use of documentation, empirically exposing how the broader context of primary health care shaped the use of PACK Child in clinical consultations.

Methods
The process evaluation used a linguistic ethnographic [30,31] methodology, which combines strengths of linguistics and ethnography to systematically investigate human behaviour in context. Linguistic ethnography provides theoretical and methodological tools for analysing how the meaning of talk, text and objects shift over time and space.
We have previously adapted this approach [32] to facilitate detailed investigation of complex healthcare interventions across macro, meso-and micro-contextual levels, drawing on Bronfenbrenner's socio-ecological model of behaviour, which conceptualises individual action as a response to socially structured processes and characteristics, organised across a layered system of relationships [33].
Mixed methods were used including quantitative and qualitative data collection and analytic approaches. Qualitative data included observations of training sessions; semistructured interviews with caregivers; clinician, policymaker and paediatric manager focus groups; documentation used in child consultations; and ethnographic observations of consultations and non-clinical areas in each facility. Quantitative methods included auditing of training attendance logs and clinician' questionnaires completed six months after finishing the PACK Child training programme. In this paper, we provide a detailed report of findings from the qualitative analysis of our observations of non-clinical areas, observed and audio-recorded consultations, documents and interviews and focus groups with primary healthcare (PHC) facility managers, senior paediatric managers and policymakers.

Research Setting
The setting for this pilot and process evaluation was 10 public-sector PHC facilities serving impoverished urban and rural communities in the Western Cape province, South Africa. Child health services within PHC facilities are provided for children aged 0-13 years. Phase One took place in a single facility, Phase Two in an additional three facilities and Phase Three in a further six facilities. The facilities were purposively selected to provide maximum variation of primary care delivery in partnership with the Western Cape Health Department's People Development Centre, which oversees training and upskilling of public sector healthcare workers in the Western Cape -see Table 1

Data collection
To understand the macro-contextual features shaping delivery of the PACK Child intervention, interviews were conducted with managers at each PHC facility, and a stakeholder focus group with senior paediatric managers, policymakers and clinicians.
Facility managers were asked about staff resource allocation to paediatric care, relevant policies, patient flow and perceptions of the PACK Child intervention for supporting the care of children. Senior paediatric managers and policymakers were asked about challenges of the current healthcare system and how they viewed the role of PACK Child in helping to address those challenges. We also conducted a documentary analysis of the structure and content of 1. The PACK Child guide, 2. The IMCI guide and checklist [9], 3.
Integrated Clinical Stationery and 4. The Road to Health Booklet (old version) [35] to understand how the broader principles underpinning these different texts are operationalised to deliver paediatric primary care (see Table 2 and Additional files 1-4).
To understand the meso-contextual features shaping delivery of PACK Child, we drew on

The PACK Child Intervention
The PACK Child guide, which is aligned with recognised standards for guideline development [36,37] is an evidence-informed, policy-aligned integrated clinical decision support tool, including algorithms that facilitate identification of likely diagnoses. The guide is designed to be adapted to LMICs globally, covering 63 common symptoms, including IMCI components such as diarrhoea and pneumonia, but importantly, it extends the scope of IMCI by focusing on children 0-13 years. It is also designed to address 16 long-term health conditions most commonly seen in primary care, as well as including a comprehensive approach to screening the well child. Routine care of the well child (see Additional file 1) includes measuring and interpreting growth, screening developmental milestones, checking immunisations, deworming, vitamin A, TB and HIV screening, as well as asking about the mental health of the child or problems in school. It also encompasses an assessment of the carer's health including screening for psychosocial risk factors such as depression, violence in the home or financial difficulties. Routine care is intended to be sequenced after establishing the need for urgent care for the presenting symptom, but before definitive care for non-urgent symptoms. Clarity around prescribing scope is provided by colour-coding each medication according to prescriber level. Designed to promote the continuum of care required to break the acute episodic care cycle, the guide prompts routine care into every consultation. Its content reinforces the messaging of existing initiatives like the Road to Health Booklet Side-By-Side messaging [35], the First 1000 Days initiative [38] and the Nurturing Care framework [39] (see Table 2).
Drawing on the successful PACK Adult training methodology [18], the PACK Child training programme used an onsite in-service cascade model (see Additional file 6) to be delivered in three phases for the pilot [19]. The first phase included one facility trained by a KTU trainer, the second phase included three facilities trained by two KTU trainers and the third phase conducted at six facilities was rolled out two by PACK Child Facility Trainersgovernment employees trained into the role by KTU during a five-day off-site workshop.
The training included eight onsite training sessions delivered weekly in the PHC facilities; this was expanded to nine during phase two of the pilot to include a "health systems session" focusing on patient flow and distribution of tasks among cadres in contact with children. The training was designed to target all cadres of clinicians at facilities, mainly nurses and doctors and emphasises the alignment of the PACK Child content to IMCI, integration of care for the child's caregiver using PACK Adult, and to develop the skills of all clinical staff to encourage a multi-disciplinary approach to paediatric primary care.
During the course of the pilot, bi-weekly meetings were scheduled to feedback on the content of the guide and issues with implementation in practice. This provided a regular opportunity to capture further refinements and clarifications in the PACK Child guide and for the training development. One of the content developers attended the training sessions in the first phase to ensure the usability of the guide and identify challenges within the primary care setting.

Eligibility and Sampling
To be eligible for inclusion in the study, nurses and doctors needed to receive PACK Child training, and caregivers and children aged birth to 13 years needed to be receiving paediatric services at the selected facilities. Policymakers needed to be responsible for delivery of primary care in public sector PHC facilities.
Data collection for the process evaluation occurred concurrently with the three phases of the pilot, enabling analysis of Phase One data to inform the sampling strategy in Phases Two and Three. All facility managers were invited to be interviewed. On a typical day, 2-3 clinicians consulted children and all were invited to participate in consultation observations. Purposive sampling was planned in Phase One to select and recruit caregivers and children and was intended to be informed by diversity of child conditions, level of deprivation and the age of the child. However, consultation observations were dependent on which children presented at the facility on the day of data collection, and on nurses identifying and approaching eligible participants in the waiting room areas. In Phase One, nurses approached all eligible participants unless they decided it would not be appropriate to do so (e.g. child needed urgent attention and the mother was distressed).
However, the limited number of children in Phase One who had a chronic condition or were older than five years informed identification and inclusion of these children in Phases Two and Three. To do so, we asked facilities to prioritise approaching caregivers of children who met these criteria. Similarly, the inclusion of only nurses in Phase One informed a proactive attempt to include doctors in Phases 2 and 3. We asked doctors in each facility if and when they consulted with children and then asked them to approach the caregiver and child about participation in the research. Senior paediatric managers, facility managers, nurses and doctors involved in the pilot; and policymakers from the City of Cape Town and Western Cape departments of health were invited to participate in stakeholder focus groups to review findings and facilitate discussions on the implications of PACK Child for wider implementation.

Committee, City of Cape Town Research Ethics Committee and the Western Cape
Provincial Health Research Committee. Written consent for interviews and observations was obtained from all facility managers, clinicians and caregivers. Children over seven years old were asked to give assent to their participation. Caregivers and children were asked to consent to interview and observation on the day they attended the clinic. Facility managers provided consent for observations of non-clinical areas. All participants were provided with written information about the research, informed that their participation was voluntary and that they could withdraw from participation at any time.

Data Analysis
To understand how PHCs were organised to provide child care, and the interaction between contextual features and intervention delivery, we firstly analysed manager and policymaker interview data, and field notes of our observations of waiting rooms and reception areas. All interviews were transcribed verbatim and thematically analysed.
Themes and field notes from observations of waiting room areas were compared to identify and describe similarities and differences in the organisation and flow of patients across facilities. Secondly, we analysed the audio-recordings, transcriptions and researcher field notes of consultations to understand how macro-and meso-contextual features shaped, and were shaped by nurse's interactions with caregivers and children. A key focus was to identify instances of how use of PACK Child aligned with routine practice, providing "telling cases" [40] of the wider social forces structuring intervention delivery at the point of delivery.
Audio recordings of consultations were transcribed verbatim. A sub-sample was transcribed using conversation analytic conventions [41,42] to provide detailed evidence of how clinician's use of the PACK Child guide was negotiated within interactions with caregivers and children. We then inductively coded each transcript by activity, for example "eliciting the child's presenting problem", "physical examination", or "advice giving". We cross-referenced these against the field notes of the researcher's observations to determine what documentation, if any, was used during each activity.
This enabled us to obtain a broad picture of the structure of consultations within and between clinicians and facilities. We then coded clinician's questions according to their function as part of the clinical assessment process (e.g. asking about presenting complaint, wider information gathering) and the structural form of the question (e.g.

Data synthesis
The analysis of qualitative data was iterative, moving between data collection and analysis to test emerging theories, comparing how managers' views related to actual implementation of primary care and use of PACK Child. For example, managers reported particular facility processes or protocols that we then compared with our observations of waiting room areas and clinical consultations. Instances of how PACK Child aligned with routine practice within consultations provided insight into the tensions between different contextual features which we could then investigate further in subsequent observations and triangulate with data obtained from manager interviews.
The synthesised data were then used to map macro-, meso-and micro-contextual features with a consideration of how national policy at a macro level impacted on the organisation and skill mix of staff at a meso level, and then ultimately how care was delivered to children at a micro level within consultations. By focusing on (mis)alignments to implementation and setting the PACK Child intervention within a contextual framework, we were able to make the transition from the identification of patterns of PACK Child use in specific facilities, to theoretical explanations of how different structural relations and mechanisms organise moments of delivery, facilitating generalisable inferences and predictions on how to optimize PACK Child for future implementation.

Results
We conducted ten facility manager interviews (one per facility); one focus group with 24 stakeholders including clinicians, policymakers and senior paediatric managers (involving four smaller group discussions); ten observations (one per facility) of waiting room and Following the high proportion of children presenting with acute infections in Phase One, we also attempted to sample children presenting with chronic conditions in Phases Two and Three. In Phase Three, one child with asthma and nine with eczema were included.
First we report how macro-, meso-and micro-contextual features of paediatric primary care had an impact on the integration of PACK Child at the point of delivery within consultations. In Tables 2 and 3 we have set out the macro and meso elements of context, with illustrative quotes from facility manager interviews. We then present extracts from the audio-recorded consultations, providing telling cases of how macro-and mesocontextual features were made salient by clinicians at a micro-contextual level, specifically in terms of how they used the PACK Child guide alongside other documentation and how they interacted with children and caregivers.
. World Health Organisation's IMCI is an integrated strategy that is targeted at illness and disability, and promoting growth and development for children 0-5 strategy comprises both preventive and curative elements and has three compon improving skills of primary care clinicians, health systems functioning, and family health practices. Principally delivered by nurses, IMCI is underpinned by a ri approach with the main aim of a provider-patient contact to ensure all children w are referred to the next level of care and provide reassurance that growth associated interventions e.g. Vitamin A) and immunisation take place.
IMCI was introduced in South Africa in 1996 with a primary implementation focus capacity building of clinicians [17]. In the Western Cape, the main manifestations chart booklet, last updated in 2014, a training programme that targets professi the intention that they then see children, and the IMCI checklist (Additional file 2).
Primary Health Care Standard Treatment Guidelines (STG) and National level guidance comprising evidence based standardised recommendation workers, in order to promote equitable access to safe, effective, and a  Flow of children through facilities Registration: For children requiring immunisations, care was typically ac an appointment system. Caregivers with a scheduled visit for an immunisa monitoring arrived with their RtHB and placed it at a specific registration p for appointments. Caregivers with children without appointments, coming condition or having missed scheduled visits, placed their RtHB in the nonbox at the registration desk. Patient records were subsequently retrieved staff and placed in the weighing and triage area according to the order in arrived.
Weighing/ and triage area: The weighing and triage area was either a r area where children were weighed and reason for the visit established. In facilities an enrolled nurse, with more limited clinical training than profess was allocated to the weighing area. Weights were measured but typically used to interpret growth. Heights were not routinely measured in most fac Temperatures were taken if the child was feverish. Both sick and well child through the weighing/triage area. Guided by the child's RtHB, the nurse d child required vitamin A and deworming medicine. Children were separate emergencies, well, or sick child visits and allocated to the relevant nurse, on the caregiver's report of the presenting complaint, rather than through clinical assessment. In two facilities, this area also functioned as the immu In one facility, children were weighed and given immunisations in the cons The triage area typically had a dehydration corner and breastfeeding area Well child: Typically seen in the immunisation room. Caregivers and child the waiting area to be called by the allocated nurse. The immunisations w carried out by an enrolled nurse but in some cases, a professional nurse. F immunisation, the nurse plotted the child's weight in the RtHB. Caregiver/ leave with their updated RtHB.
Sick child: Between one and three nurses in each facility were allocated children. These nurses were generally professional nurses, who then repor nurse practitioner or doctor. In two facilities, sick children were prioritised adults. If the child was classified as an emergency, they went straight to t Most of the consultation rooms for sick children had a stock of medication in some cases, caregivers had to go to the pharmacy to collect their presc facility, caregivers/children were required to see approximately four peopl treatment for Prevention of Mother to Child Transmission (PMCT) of HIV, in to: triage, give immunisations, treat acute conditions and deliver PMTCT. Pattern of care-seeking from PHC services The primary health care service offering is chiefly structured as preventive (immunization and growth monitoring) and curative (acute illness), both in 5, which over time has shaped care-seeking patterns at community level. chronic illnesses such as asthma rarely receive routine care in primary car referred to secondary and tertiary services which are usually some distanc communities, or the Community Health Care Centres where there is little c care outside HIV and TB treatment programmes. This perpetuates poor ca outside acute episodic illnesses and does not grow an understanding of re care for children with long-term health conditions. Caregivers frequently m extensive network of private General Practitioners who provide acute epis medication for a fixed fee, but rarely chronic care. I: Do you think many children come with a chronic illness proble come with an acute symptom? M: The majority is acute symptoms, but here and there we have on asthmatic treatment also, but the majority is acute, and the pneumonia cases, severe pneumonia cases. (Manager Interview Referrals and continuity of information Facilities reported rarely receiving feedback from hospitals following patie Caregivers received discharge summaries from referral centres but did no them to PHC facilities.
We now focus on the interaction between a health system geared towards preventive care

Clinical assessment questions
In our sample of 53 audio-recorded consultations we identified and coded 1218 clinical assessment questions. questions with "what", "where", "why", "how" formulations). Polar questions [45] are questions that are either interrogative or declarative and are designed to prefer either a "yes" or "no" response. In the process of clinical assessment, clinicians' use of polar questions have also been shown to frequently prefer no problem answers [33,46]. For example, "And she is weeing ok?" is a declarative question designed to prefer a yes and rule out dehydration, whilst the inclusion of "at all" tilts the interrogative "Has she Child intervention does not specifically prompt clinicians to elicit caregiver's perspectives, this finding suggests that the clinicians in our sample did not habitually ask questions that attempted to gain a picture of the child beyond the specific problem presented on the day.
Taken together, these different features of clinical assessment questions suggest that clinicians were negotiating an institutionalised practice to treat symptoms as acute episodes that need to be assessed according to level of risk on the day, with a different approach which views symptoms as potential indicators of underlying conditions. In doing so, clinicians could be seen to be operating in a transitional space between a risk minimisation approach on the day to risk minimisation over time. The challenge in making this transition is most clearly seen in the use of polar questions to elicit psychosocial issues. Rather than viewing the predominance of polar questions designed to limit disclosure of psychosocial issues as a failure of nurse performance, we can see these questions as a manifestation of the wider healthcare system in which they were operating.
Working within an everyday context where large numbers of children from impoverished backgrounds with high rates of adversity present with acute symptoms that clinicians need to assess for risk, monitor growth, check immunisations and feeding in busy, timeconstrained consultations with limited confidential spaces and referral resources, it is unsurprising that nurses adopted to phrase these questions in such a way that it limited the possibility of disclosure of sensitive psychosocial problems.

Introducing the PACK Child guide into routine consultations
Box 1: Nurse navigating PACK Child with IMCI checklist and RtHB Consultation from a Phase 3 PHC facility with a mother and three-year-old girl presenting with a cough she has had for three days. The nurse begins the consultation using the IMCI checklist where she documents the cough as the presenting symptom, enquires about the presence of diarrhoea and the caregiver shows the nurse the child's skin rash. The extract begins after 2 minutes into the consultation. A:nd three months N Two years and thre:e months. Two years is here, we must check the weight. Let's see the weight, the weight is 16 and where is he:r card? Is here ((child coughs)). HAIBO ((surprised expression in isiXhosa)) SISI you are coughing ne: ((Afrikaans particle word meaning "isn't that so" used for emphasis)) N reading from ro N searching for R In a Phase 3 facility a 12-year-old boy presents for an appointment with an ear problem. During the consultation the caregiver voluntarily discloses that the child has a history of Fetal Alcohol syndrome, takes Ritalin for behavioural problems (implying likely involvement of tertiary service because of limited access to Ritalin), and has a difficult relationship with a largely absent mother. Despite evidence that the nurse is listening to the caregiver's concerns about family life, the nurse does not discuss the child's use of tertiary or social services and she does not refer to the PACK Child guide which includes pages on how to manage behaviour and anger problems as well as potential child abuse.

High pitch
Underline -spoken with emphasis […] sequence of consultation not included

Use of PACK Child guide N:
Is is his own mother still involved in his life?
Opens to contents page (0.7)

CG:
[She's her father] is her father is raising two kids of hers those two are working now.
(1) Her father is also a FAS ((Fetal Alcohol Syndrome)) baby (1) I say every father gets his packet.

N:
Mhm CG: They gave him she had tw::o, three children minimum, by a gu:y, two boys and a a girl and she dropped the children by the father and she left (1) she's now she is a year gone from there now.

CG:
And here he is if she comes she just come and then he fights with her (1.5) because she pu::lls him and they've got that anger. And and I tell her she mustn't pull him because he don't like people to pull him around, and she got a habit of that 'Kom met my saam', 'come with me now', you know? (1.5) so many times and I told him, 'you mustn't fight with a mother' that is still your mom (1) irrespective. (1.5)

N:
So you said he is got sore throat? Box 3. Using PACK Child to make a transition from acute symptom to chronic illness management In a Phase 3 facility a four-year-old girl reports to the clinic with a cough, recurrent wheeze and at the beginning of the consultation the mother reports that the child has asthma. The child was nebulised before the consultation, and no wheeze is heard on auscultation by the nurse. The expected route through the PACK Child guide would be to start with the routine care page for every visit, then refer to the wheeze symptoms page to manage acute symptoms, finishing with the asthma routine care in the long-term health condition section.
The clinical nurse practitioner initially refers to the cough page in the PACK Child guide and then navigates to the recurrent wheeze page. She diagnoses the child with allergic rhinitis and prescribes a nasal spray and cetirizine. The mother reports having enough "pumps" but the nurse doesn't clarify what this includes and prescribes budesonide metered dose inhaler, advising the caregiver that it needs to be taken twice a day and Ventolin (salbutamol) used when necessary. The nurse only briefly refers to the asthma routine care page and does not ask the caregiver about the child's history of exacerbations or hospitalisations. However, following PACK Child the nurse advises the caregiver to book a review appointment in three months. The extract in Box Two demonstrates a lack of information provided by tertiary or social services surrounding the child's behaviour and problems with his parents, with the nurse needing to decide how to respond within the constraints of a time-limited consultation which also required her to tackle the child's sore throat symptoms. Despite the availability of pages within PACK Child that guide the clinician on how to manage symptoms of behaviour, anger and abuse, thereby offering the opportunity for the nurse to support continuity of care between primary and tertiary services, the nurse instead redirects the focus from a complex set of psychosocial issues back to the acute physical symptom.
In contrast, the extract in Box Three illustrates a nurse operating in the transitional space between a health care system structured to focus on treating acute symptoms and PACK Child that supports ongoing care of long-term conditions. The clinical nurse practitioner, using the PACK Child guide is able to prescribe an inhaled corticosteroid for asthma, successfully diagnose comorbid allergic rhinitis, and books a follow-up appointment for the child. However, the nurse doesn't explore which inhalers the child is already using, follow the guide as instructed in the training programme, or ask questions about previous exacerbations or hospitalisations.
Boxes 1-3 provide "telling cases" [40] which empirically expose a broader tension between a primary care system oriented to acute symptom management and PACK Child's focus on care for the child over time, illustrated through nurses' use of different documentation (Box 1); tensions between PACK Child's orientation to routine care and psychosocial issues and a healthcare system oriented to acute physical symptoms (Box 2); and nurses having some success in using PACK Child to treat chronic conditions but struggling to orientate to a view of the child's condition over time (Box 3). These instances triangulate with the ethnographic observational data (Figure 1) that showed a predominance of children under 5 presenting at facilities with acute symptoms, interviews with facility managers who reported children with chronic illnesses were routinely referred to tertiary level hospitals (Table 3), and the analysis of questions ( Table 4) that found clinicians predominantly asking questions required by IMCI, psychosocial questions designed to minimise rather than invite disclosure of problems, and a scarcity of questions that attempted to elicit caregiver perspectives or the child's medical history.

Discussion
By investigating the use of PACK Child within a broader contextual framework we were able to develop hypothetical propositions for optimising the implementation of PACK Child on a wider-scale. Importantly, and in contrast to previous observational research of paediatric primary care in LMICs [28][29][47][48], this approach facilitates the generation of strategies for strengthening the healthcare system that may greatly enhance the impact of training and the practice of clinicians within paediatric consultations.
At a macro level, our evidence strongly suggests that the current paediatric care offering urgently needs revising to facilitate enhanced skills, knowledge and deployment of nursing staff with the right levels of expertise to better address the acute illnesses of children of all ages but also to more adequately treat and support children living with long term health conditions. Such conditions may include a complex mixture of physical, behavioural, psychological and social problems that are being sustained and perpetuated over time. PACK Child was designed to meet these needs if structural changes facilitate a clinical practice that orientates to continuous rather than episodic care. Previous evidence has already emphasised the need for a more systematic implementation programme of IMCI [49, 50], and for not relying solely on training to improve quality of care. Our evidence supports this recommendation but emphasises that without reorienting primary health care towards a view of the child and family evolving over time, the full range of health and social needs of children will remain unaddressed [13].
At a meso level, the capacity for clinicians working in a busy facility environment to deliver care that adequately addresses a complex array of needs, whilst also meeting provincial requirements to complete documentation is clearly challenging. In addition, while in theory comprehensive services are available for selected conditions at facilities, caregivers and children often have to see multiple clinicians in order to receive the care they require. Additional touchpoints are likely to entail increased loss to follow-up, are not person-centric, may be an inefficient use of clinical resources as well as presenting infection control risks for children. The PACK Child guide is designed to support clinicians to provide more comprehensive care without unnecessary duplication but requires facilities to consider how best to deploy staff resources to meet this objective. The inclusion of a "health systems strengthening" session within the PACK Child training programme (Additional file 6), which asked clinicians to examine the distribution of roles at different points in the facility visit, represents an initial attempt to streamline care. The evolving use of digital technologies also offers potential for supporting streamlined care and ensuring continuity of information across contacts, and lessons learnt from piloting digitised versions of PACK guidelines have already been reported [20]. At a micro level, detailed consideration is required regarding how to better integrate medical record stationery alongside PACK Child, so as to streamline and free up consultation time, which will allow for more involvement of caregivers and children.
Consultations have to be optimised to maximally benefit the child, not just in terms of their specific problem on the day but an approach that enables the child's history and onward referrals to be tracked and followed on through at subsequent consultations and with different professionals. In this respect the ICS offers advances over the IMCI Checklist and has been adopted for Province-wide implementation since completion of this study.
Caregivers provided detailed accounts of their children's healthcare utilisation and symptoms in this study, and should not be overlooked in systems that cannot guarantee continuity of provider.

Strengths and Limitations
This process evaluation was to our knowledge the first study in LMICs to use a linguistic ethnographic methodology to map salient macro-, meso-and micro-contextual features of child health systems and attempt to identify relationships between different contextual features and the implementation of a complex healthcare intervention within clinical

Conclusions
More than two decades since IMCI was introduced, our findings reveal that a review of the informed consent was obtained from caregivers (parents or guardians). Children over seven years old were also asked to give assent to their participation.

Consent for publication:
All participants have consented for the findings of the study to be published with their identity anonymised.

Availability of data and materials:
The datasets generated and/or analysed during the current study are not publicly available due to data transcripts including personal participant information not suitable for sharing, but are available from the corresponding author on reasonable request.  Observation of waiting room, triage and reception area