|Abstract: ||Background. Developing countries are undergoing a process of epidemiological transition from infectious to non-communicable diseases, described by the United Nations Secretary General Ban Ki-Moon as “a public health emergency in slow motion”. One of the most prevalent of these diseases, in sub-Saharan Africa, is hypertension, which is a complex chronic condition often referred to as the “silent killer” and a key contributor to the development of cardiovascular and cerebrovascular diseases. Hypertensive patients in this setting are estimated to increase from 74.7 million in 2008 to 125.5 million in 2025, a 68% increase. There is however an important gap between emerging high-level policies and recommendations, and the near-absence of practical guidance and experience delivering long-term medical care for non-communicable diseases within resources-limited health systems. To address this gap, our study consisted of field investigations to determine the minimum health systems requirements necessary to ensure successful delivery of anti-hypertensive medications when scaling-up interventions.
Methods/Design. A cross-sectional analytic study was conducted in the Western Cape Province of South Africa using a mixed method approach with two sets of semi-structured interviews and simulation modeling. One set of interviews was conducted with health professionals involved in the care of hypertensive patients within nine community health centers (five urban and four rural) to understand the challenges associated with their care. The other set was used to map and assess the current supply chain management system of antihypertensive medications and involved key informants at different levels of the process. Finally, modeling and simulation tools with ARENA Software were used to estimate minimum numbers of health workers required to ensure successful delivery of medications when scaling up interventions.
Results. The study found numerous challenges affecting the care of hypertensive patients in primary health care facilities and categorized these into five interconnected dimensions: Management of the visits within the PHC facility, Adequacy of human resources, Standardization of patients’ care, Infrastructure limitations, and Patients’ responsibilities. Potential solutions to overcome these challenges were explored in order to improve the care of the hypertensive patients in the PHC facilities. Mapping of the drug supply chain management system highlighted the complexity of the system. In fact many of the issues reported fell outside of the control of the provincial health department. The need for a more single comprehensive computer system to handle most of the functions of the drug supply management system was heavily emphasized. The modeling and simulation tool with ARENA Software estimated the type and number of health care professionals needed to provide appropriate services to a certain patient population based on the set targets. The sample data used showed how one can test the impact of various changes in the processes and staffing levels to minimize waiting times while increasing the daily patients’ intake at the facility. We found that with few additional nursing staff, that are more affordable and quicker to train than medical doctors and pharmacists, one can considerably improve the performance of the facilities in the care of hypertensive patients.
Discussion. This investigation has highlighted the detailed processes in place for the care of hypertensive patients in primary health care facilities, identifying the challenges in providing such care. The potential solutions suggested by the study results, if implemented, should help improve services offered and ensure that the system remains sustainable when patients’ intake increases exponentially as a result of scaled up interventions. The weaknesses of the drug supply chain management system demand immediate action. The modeling and simulation tools used in this study, if used on an ongoing basis, could create more effective planning of needed resources, although their proper utilization will require extra training for managers. Whether there is sufficient political support to ensure the resources necessary to reach the provincial health department’s hypertension target remains to be seen, and would benefit with further economic studies to estimate the cost associated with tackling the hypertension epidemic.|