How to improve hypertension care

•WHF, NHF seek inclusion of hypertension in BHCPF scheme, PHC programmes, others
•Proffer solutions on reducing morbidity, mortality from high blood pressure to 30% by 2030

Medical experts under the auspices of the World Heart Federation (WHF) and Nigerian Heart Foundation (NHF) have made 25 recommendations on how to improve hypertension care in Nigeria.

The medical experts in a communiqué released after a the Roundtable Meeting titled “Management of Hypertension in Nigeria: Strengthening Primary Health Care System through Task Shifting and Basic Health Care Provision Fund”, which held at the Nigerian Institute of Medical Research (NIMR), Yaba, Lagos, last week, have called for the inclusion of hypertension in the Basic Health Care Provision Fund (BHCPF) scheme/ State Social Insurance scheme and inculcation of routine screening for hypertension and identification of risk factors at the Primary Health Care (PHC) level.

A consultant cardiologist and Executive Secretary of NHF, Dr. Kingsley Akinroye, signed the communiqué.

Akinroye said Nigeria’s commitment to Universal Health Coverage has been symbolised by the passage of the National Health Act of 2014, which in section 11 mandates the establishment of a BHCPF to support the effective delivery of PHC services, provision of a Basic Minimum Package of Health Services (BMPHS) and Emergency Medical Treatment to all Nigerians with priority given to the poor and vulnerable groups in the population.

He said although the April and November, 2018 BHCPF Operational Guidelines defined a very lean BMPHS, which only had blood pressure measurement and urine sugar estimation for screening of hypertension and diabetes respectively, lessons learnt from piloting the scheme led to the advocacy for a more robust package and a different Provider Payment Mechanism (PPM), which led to the review of the guideline.

Akinroye said in 2020 a new BHCPF Guideline was approved by the National Council on Health, which incorporated primary and secondary treatment of hypertension, diabetes, sickle cell and mental health and renal disease management.

The cardiologist said the overall aim of the BHCPF is to significantly move Nigeria towards achieving Universal Health Coverage (UHC);to achieve at least one fully functional public or private PHC facility in each political ward; at least 30 per cent of all wards over the next three years, 70 per cent within five years, and 100 per cent within seven years from 2019; to achieve at least three fully functional public or private secondary health care facilities, benefitting from the BHCPF in each state; at least 50 per cent of all states over the next three years, and 100 per cent within five years; to establish effective emergency medical response services in 36 states and the Federal Capital Territory (FCT) in five years, including a national ambulance service; to reduce out-of-pocket expenditure by 30 per cent in five years and increase financial risk protection through health insurance; and to increase life expectancy to at least 60 years over the next 10 years.

OTHER recommendations on how to improve hypertension care in Nigeria, according to the communiqué, include: Provision of adequate and appropriate equipment, human and financial resources at the PHC centres; ensure a two-way referral system between the PHC and Secondary/Tertiary Healthcare facilities; increased commitment to include People Living With Cardio Vascular Diseases (PLWCVDs) in decision-making process on access to hypertensive care, screening and treatment; complete implementation of Task-Shifting Task-Sharing (TSTS) policy; streamline guidelines for the management of hypertension; wide-spread advocacy for front of package labeling; standardised use of simple treatment protocols at the PHC and Secondary Health Care (SHC) levels; adopt a simplified model of treatment for hypertension; training and re-training of healthcare workers at PHC level; increase access to medication and medical devices at PHC and community levels; increase government funding for the prevention and management of hypertension; community behavioural change and communication on hypertension through mass community entry; leverage the existing community health interventions at the community level; and strengthen advocacy and support for hypertension at national, sub-national and community levels.

The medical experts also called for improved hypertension data documentation on the national database example Data Use for Health Information System 2 (DHIS2); domestication of World Health Organisation (WHO)-Hearts strategies; continuous capacity building for service providers especially at the PHC level; more collaboration of all stakeholders involved in hypertension prevention and management; improve telemedicine for the management of hypertension at the community level; encourage partnerships with telecommunication providers for the management of hypertension; develop a policy on salt consumption and reduction; create awareness on salt consumption and reduction among students; targeted media engagement for prevention and management of hypertension; and develop policy documents on climate change and insecurity to guide prevention and management of hypertension.

CHAIRMAN, Executive Council, NHF, Dr. Femi Mobolaji-Lawal, in his presentation at the stakeholders meeting, said the main objective of the meeting is to provide a forum for major stakeholders to interact, discuss, identify challenges, and proffer solutions on reducing morbidity and mortality from hypertension by at least 30 per cent by 2030 in Nigeria through improved hypertensive care and financing of the PHC system. Mobolaji-Lawal said, in addition, it aims to increase the knowledge of policy makers and other stakeholders on management of hypertension and educate them on strategies for domestication of the Task Shifting policy at sub-national levels and optimal utilisation of BHCPF in management of hypertension.

He said NHF developed and published in 1996, together with The Nigerian Hypertension Society, Guidelines for the Management of Hypertension in Nigeria. NHF also launched the Heart-Mark Food Labelling (NHF-HMFLP) Programme in 2003. This aimed at a simple way to guide consumers to select heart-healthy options, promote consumer education and collaborate with the industry for product improvement. Recently, the Foundation investigated consumers’ perception of Front-of-Pack labelling in Nigeria and the outcome of the study has been published in an academic journal.
A professor of public health, a consultant public health physician and epidemiologist at the Department of Community Medicine College of Medicine University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH) Idi-Araba, Akinsanya Osibogun, who is also the President of the National Postgraduate Medical College of Nigeria, in his presentation, titled “Task Shifting Intervention: An Effective Strategy To Manage & Control Hypertension In Nigeria”, said task shifting is a process of delegation whereby tasks are moved from highly specialised to less specialised health workers.

Osibogun said task shifting could make more efficient use of the human resources for health currently available by reallocating tasks among health care workers

He said the National Task Shifting and Sharing Policy is aimed at changing the curriculum for pre-service education and in-service training to produce more knowledgeable and skilled health care workers.

The public health physician said task shifting could be effective in the short run; however, it may not be a sustainable method for the long run.

Osibogun said the sustainability of TSTS is dependent on training and re-training of the above-named health care workers, their supervision, availability of equipment and supplies supported by adequate and regular funding.

“TSTS will expand and increase access of patients to screening, prevention, care and treatment services,” he said.

Professor of Medicine/Consultant Cardiologist at the University of Nigeria Teaching Hospital (UNTH), Enugu, Basden Onwubere, in his presentation titled “Guidelines on Treatment of Hypertension, Existing Programmes and Initiatives on Hypertension Management in Nigeria”, said more people die each year from cardiovascular diseases than from any other cause and it is estimated that 1.28 billion adults aged 30-79 years have hypertension, with more than two-thirds living in low- and middle-income countries.

Onwubere said in poor resource settings, cognizance should be taken on the socio-economic peculiarities of the population in focus. He said different population groups and societies are encouraged to develop evidence-based guidelines based on local peculiarities.

The cardiologist said several hypertension programmes are currently going on in collaboration with national and international interest groups and association in hypertension.

Director, Scientific Affairs, NHF, Prof. Isaac Adebayo Adeyemi, said curbing the rising incidences of hypertension with the expected population increase (263 and 401 million by 2030 and 2050 respectively) in Nigeria calls for a multi-stakeholders approach within national and global best practices.

Professor of Public Health and Community Medicine, Prof. Obehi Okojie, who spoke on “The role of community health workers in prevention, treatment and care of hypertension”, said health workers are critical to addressing this emerging public health burden.

Okojie said in light of critical shortages in the health workforce in LMICs, community health workers (CHWs) are increasingly recognised as an essential part of the health workforce needed to achieve these public health goals.

“CHWs provide cheaper alternatives that form the backbone of most primary healthcare (PHC) services for the management and control of both communicable and NCDs,” the public health physician said.

On the way forward, Okojie said community organisations working with CHWs should provide training and retraining on cardiovascular disease prevention and self-management to increase CHWs’ skills and competencies.

The physician said CHWs should work directly with community pharmacists to assist with health education at the point of medication pick-up and organisations employing CHWs could partner with others, including state health departments and Area Health Agencies on education, employers, and CHW networks to develop statewide standards for education and practice.

To best work with CHWs, Okojie said providers and systems should consider how to assess CHW performance, patient satisfaction, system integration or changes, and contributions to hypertension management.

The public health physician said clear guidelines paired with competency-based, ongoing training for CHWs and other team members are required to enhance and solidify their integration in the care team.

Okojie said preference should be given to CHWs interventions focused on behaviour change communication and lifestyle counselling for reduction of high blood pressure for both hypertensive and normotensive individuals.

The doctor said there is a need for adoption of standard curricula for training of CHW for the control and management of hypertension to guide translation of such interventions in different settings especially in LMICs.

“Ultimately, fine-tuned communication and collaboration among CHWs, other team members, patients, and community resources will improve population health equity, hypertension and other cardiovascular disease outcomes,” Okojie said.

Prof. Akindele Adebiyi, in his presentation on “Nigeria Country Mapping Report” on behalf of the Nigerian Heart Foundation in partnership with the World Heart Federation, said more people die yearly from cardiovascular diseases than from any other cause.

Adebiyi said generally, hypertension is: systolic blood pressure (SBP) ≥140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg.

He said hypertension significantly increases the risk of heart, brain, kidney, and other diseases and is a major cause of premature deaths worldwide and uncontrolled hypertension imposes an enormous economic burden on society direct health care costs and substantial productivity losses disability and premature mortality.

He said the financial burden of hypertension and its consequences can also be catastrophic for single households and despite this understanding, critical roadblocks to control exist such aslow awareness and low/poor access to screening and care.

Adebiyi said a mapping exercise was conducted aimed at identifying roadblocks and potential facilitators for the effective implementation of the WHO Guideline for the pharmacological treatment of hypertension in adults, based on the WHF roadmap on hypertension.

The physician said it was purposed to collect and synthesise available information on hypertension and hypertension management in Nigeria to better understand the local context and identify potential roadblocks undermining hypertension prevention and control in the country.

Adebiyi said this final report is expected to guide and support the discussion during the stakeholder roundtable, which follows this presentation. “The roundtable will ideally concretise actionable solutions to the roadblocks identified in this report lead to the development of evidence-based policies and strategies that will contribute to improving the management of hypertension in Nigeria,” he said.

Executive Secretary, Osun Health Insurance Agency and Pioneer Chairman, Forum of Chief Executive Officers (CEOs) of State Social Health Insurance Agencies in Nigeria, Dr. Adeniyi Samuel Oginni, in his presentation titled “Integration of BHCPF into Management of Hypertension in Nigeria”, said worldwide, Non Communicable Diseases (NCDs) are the global leading cause of death killing 41 million people each year.

Oginni said, in Nigeria, the six major NCDs causing high level mortality and morbidity are: cardiovascular diseases (CVDs), diabetes mellitus, chronic respiratory diseases, diabetes mellitus, sickle-cell disease, and mental, neurological and substance use disorders.

He said hypertension is the major cardiovascular disease in Nigeria with a pooled prevalence of 31.2 per cent (men 29.5 per cent, women 31.1 per cent) and only about one-third are on treatment. Hence the need to provide equitable access towards achieving UHC and improving population health outcomes.

Oginni said care of hypertension defined in the primary care of the BMPHS is routine screening and referral for diabetes mellitus, hypertension, and other chronic diseases to secondary facilities.

Nevertheless, he said the current staff strength, infrastructure; medicine supply and governance of the PHCs and even referral secondary facilities are far inadequate to deliver seamless quality management of hypertension.

Oginni said there is therefore a need to provide the right mixes of staff in terms of number and qualification as well as strong institutional arrangements for effective referral system to be able to deliver these services in facilities accredited for BHCPF.
Consequently, he said the WHO HEARTS Strategy for management of CVDs in Primary Care Centres especially in LMIC should be employed in order to strengthen the capacity of focal PHCs to deliver quality management to patients with hypertension and other CVDs.

The HEARTS technical package provides a strategic approach to improving cardiovascular health. It comprises six modules and an implementation guide. This package supports Ministries of Health to strengthen CVD management in primary care and aligns with WHO’s Package of Essential Non communicable Disease Interventions (WHO PEN).

HEARTS modules are intended for use by policymakers and programme managers at different levels within Ministries of Health who can influence CVD primary care delivery. Different sections of each module are aimed at different levels of the health system and different cadres of workers. All modules will require adaptation at country level.

Oginni said BHCPF provides: an enabling policy environment to deliver primary and secondary services for hypertension (BMPHS); an opportunity for increased funding of focal PHCs to engage in continuous quality improvement and capacity building for effective management of hypertension and other CVDs (SPHCDAs and SSHIAs); community engagement and inclusion in the operations of the focal PHCs (WDCs) engendering accountability and transparency; encouragement for states in the federation to establish Emergency Medical and Ambulance services for effective referral system to enhance management of hypertensive emergencies; geographical access to healthcare services by rural dwellers that constitute about 70 per cent of Nigeria’s population (a focal PHC centre per political ward); and financial protection for poor and vulnerable persons (the BMPHS in BHCPF is delivered free of charge) thus encouraging inclusion and equitable access to care.

Oginni concluded: “Hypertension, diabetes, sickle cell disease and mental health are already incorporated into the BMPHS of BHCPF. Services for these diseases are to be provided at both primary and secondary level for beneficiaries.

“Nevertheless, the current status of accredited facilities in most states of the federation with respect to manpower, availability of equipment, essential medicines and consumables and poor governance and accountability makes them incapable of effective management of hypertension.

“Domestication of the WHO Hearts strategy, especially the team-based care which encourages task sharing will go a long way in enhancing the capacity of the facilities to deliver the required CVDs services contained in the BMPHS of the BHCPF.”