Background: World Health Organization prioritizes strengthening of cardiovascular disease care in primary healthcare (PHC). To achieve this, Nigeria is promoting task-sharing by non-physician healthcare workers (HCWs) due to shortage of physicians and other highly-skilled HCWs in PHC facilities. This study assessed task-sharing pilot for hypertension control in PHC facilities under Nigeria Hypertension Control Initiative of the Federal Ministry of Health (MOH).
Methods: A cross-sectional study was conducted using key informant interviews. Six stakeholders were purposively selected from Ogun and Kano States’ MOH and the Federal MOH due to their roles as focal persons of health programs practicing task-sharing and who had experience with task-sharing in hypertension control program. Interview guide was developed to evaluate task-sharing in the pilot program. Data were analyzed using thematic analysis.
Results: Respondents reported some strengths associated with task-sharing which include availability of non-physician HCWs, national guidelines for task-sharing practice, improved efficiency in health service delivery, reduction in patients’ waiting time, and improvement in achieving universal health coverage. The identified challenges included staff attrition, staff fatigue, professional territorialism, and non-physician HCWs reported to go above their task authorization. Respondents reported improved access to care in some PHC facilities due to task-sharing by non-physician HCWs. Respondents perceived that training and supportive supervision are strategies to ensure the successful implementation of task-sharing.
Conclusion: This study notes that task-sharing from established health programs and the ongoing piloting on hypertension control has improved service delivery. Nigeria may be able to implement nationwide task-sharing for the control of hypertension through PHC.
Keywords: Task sharing, Hypertension, Primary healthcare, Health personnel, Policy, Nigeria
INTRODUCTION
The World Health Organization (WHO) African region has a prevalence of raised blood pressure of 35.5% for both sexes combined, one of the highest of all the WHO regions worldwide.1 A study conducted in 2017/2018 found the prevalence of hypertension was 38% in Nigeria.2
However, in many countries, only trained medical doctors and other highly skilled health workers are allowed to diagnose hypertension and prescribe anti-hypertensive drugs.3 As most doctors work in the secondary and tertiary health facilities, Nigeria lacks the human resources to manage hypertension, one of the major risk factors for cardiovascular disease, at the primary health care level. The primary health care workforce is dominated by non-physician health care workers especially nurses and diploma-level community health extension workers (CHEWs),4,5 few of whom are authorized to carry out tasks that could increase the diagnosis and management of hypertension.
To strengthen hypertension care at the primary health care level, the Nigeria Hypertension Control Initiative (NHCI) was launched in November 2020 under the Federal Ministry of Health (FMOH),6 and the FMOH developed a policy7 detailing the rules and guidelines for task sharing among the primary health care workforce and began piloting this scheme intended for two years in Ogun and Kano States.
Task sharing is the expansion of the levels of health care providers who can appropriately deliver health services.8 It enables the expansion of tasks to low and mid-level health workers to safely provide clinical tasks.
A systematic review/meta-analysis of 31 studies found that task sharing interventions were effective in the control oF hypertension.9 Resolve To Save Lives reported that a team-based care approach using task sharing, was an effective way to reorganize service delivery to meet the demand on hypertension control.10
The FMOH policy allowed for task sharing activities to include blood pressure measurement, prescribing and dispensing anti-hypertensive medicines, adherence counseling and pharmacovigilance.7 The policy required that patients who would be managed in the primary health care facilities through task sharing would be those who were clinically stable, not pregnant, and did not have uncontrolled complications.7
This study was conducted by the researchers to assess the task sharing pilot for hypertension control in primary health care facilities under the NHCI.
MATERIALS AND METHODS
Study design:A cross-sectional study was conducted using key informant interviews for the collection of qualitative data.
Settings: The NHCI promoted task sharing for treatment of patients with hypertension in primary health care facilities with continuous increase in the number of facilities in the pilot program. Different levels of health care workers in these health facilities were trained prior to the commencement of the task sharing for hypertension management pilot. All levels could perform the tasks of blood pressure measurement, adherence counseling, pharmaco- vigilance and reporting of adverse reactions. Only medical officers, nurses, pharmacists, community health officers and CHEWs could prescribe anti-hypertensive medicines (Table 1).7
The NHCI’s hypertension treatment protocol has the following steps:
Step 1: If blood pressure >140/90 mmHg, start amlodipine 5mg.
Step 2: After one month, measure blood pressure again. If still high, treat with amlodipine 5mg + losartan 50mg.
Step 3: After one month, measure blood pressure again. If still high, treat with amlodipine 10mg + losartan 100mg.
Step 4: After one month, measure blood pressure again. If still high, treat with amlodipine 10mg + losartan 100mg + hydrochlorothiazide 25mg.
Step 5: After one month, measure blood pressure again. If still high, refer for specialist hypertension management.
Note that if initial blood pressure >160/100 mmHg, but < 180/110 mmHg, start at step 2. If initial blood pressure >180/110 mmHg, give step 3 drugs and refer to the emergency unit of the nearest general hospital within one hour.
The study respondents were recruited in April 2022 and data were collected through key informant interviews between April and May 2022 using an interview guide developed by the researchers. This was to explore task sharing during the implementation of the pilot program in Kano and Ogun States which were selected for geographical representation of north and south of Nigeria respectively.