This study unveils health facility barriers to good quality of care for hypertensive patients, particularly i) the lack of availability of guidelines and clinical protocols for management for use by health professionals; ii) the absence of standardized risk stratification, follow up and referral; iii) deficient strategies to ensure continuum of care; and iv) low availability of key consumables for laboratorial diagnosis and medicines. These organizational weaknesses increase the risk of poor outcomes, particularly in patients already with complications, or who have grade II hypertension and/or associated risk factors.
Mozambique’s low rates of medical doctors and trained specialists [12,13] - as well as nurses and allied professionals - are among the lowest in the world. To address the lack of workforce to tackle endemic infectious diseases (such as malaria, tuberculosis, HIV/AIDS and neglected parasitic diseases) the NHS has accommodated cadres with basic- and mid-level training who are trained for triage and management of simple cases, using algorithms for diagnosis, management and referral [14] Most of these clinical guidelines are recommended or endorsed by the WHO, and are easily incorporated in the health systems due to being largely subsidized by international funding organizations. In contrast, for NCD clinical protocols and management algorithms are still not consensual, and rarely used in our setting, despite their known role in improving the quality of care. While recognizing that the number of cadres is reduced, lack of risk-based management, unavailability of standard evidence-based clinical protocols and low access to essential anti-hypertensive drugs [15]—all essential to ensure high quality of care and prevent complications - are major gaps in hypertension care. Addressing these gaps would allow standardization of care provided by front-line health workers and probably improve outcomes in secondary level health facilities. Indeed, the fact that hypertension-related complications have become more diagnosed at secondary and tertiary care levels in some settings in Africa, is probably indicative of poor management of hypertensive patients at primary health care level.
Because ED in low-income settings are often the first contact point of patients with the health system, strategies to reduce lost opportunities for early diagnosis, prompt management and secondary prevention are needed. ED may be the only or most used form of contact with the health system for certain population groups in our health system, particularly adolescents and men who are not covered by the strong maternal and child health care programs. Owing to the high prevalence of hypertension in Mozambique [3],, point-of-care diagnostics tools—for instance rapid testing for biomarkers, portable electrocardiography and bedside ultrasound –should be used to facilitate risk stratification, detection of co-morbidities and identification of complications such has heart failure and kidney disease. In addition, clinical protocols must be made available to allow immediate treatment of those at high risk of target organ damage. Moreover, despite recognizing that ED are not the ideal setting for patient health education, counseling on healthy lifestyle, risk-free behavior and adherence to therapy to selected populations should probably be considered in such setting, to avoid loss of opportunities to prevent complications, to reduce hypertension-related morbidity and mortality, as well as to support continuity of treatment after diagnosis. The use of preventive medicine health workers - who are currently involved in maternal and child health disease prevention—would probably be an important step towards better control of hypertension, if these professionals are trained to provide counseling and non-pharmacological therapy inside the health facility.
Inadequate supply of medicines is a major determinant for inadequate anti-hypertensive treatment and catastrophic spending in poor households, and may (at least partially) explain the low levels of control in Mozambique. [3,6,16] Access to public hospitals is virtually free; patients pay $0.02 at entry points for all procedures within the health facility and $0.08 per full prescription, the total amount charged corresponding to 0.1% of the country’s minimum wage [17].. However, out-of-pocket expenditure for continuum of care in hypertension may be prohibitively expensive for the poorest households, as communities have high levels of poverty and informal employment, and almost no access to affordable private health insurance mechanisms. In Bangladesh, NCD-afflicted families allocate a greater share of household expenditures for medical care than households without NCDs, and have almost seven times higher probability of incurring catastrophic medical expenditure, as well of selling assets or borrowing from informal sources to finance treatment cost [18]..
A considerable proportion of the household budget for families living on the national minimum wage is used to buy anti-hypertensives (Figure 3),, taking in account that one patient does more than one hypertensive medicine. Medical therapy entails large out-of-pocket expenditures and increases the likelihood of household impoverishment as shown in Kyrgyzstan, where households with an hypertensive patients had significantly higher total expenditure on health and drug therapy, thus being more prone to catastrophic health spending.[16] Similarly, it has been shown that patient costs associated with obtaining care for hypertension in public health care facilities in Kenya include substantial direct and indirect costs, as well as high rates of catastrophic costs.[19] Therefore, systems to assess the unmet needs of anti-hypertensive drugs, improve the whole supply chain in the public sector and financial risk protection for patients from these poor communities are needed.
Health System related factors impact on the capacity to control blood pressure control [20–22] In African countries Health Systems are primarily oriented to managing infectious diseases, and therefore health professionals are unprepared to deal with NCD, given the scarcity of resources in health facilities [23].. The strategy of task-shifting - defined as the rational distribution of health care duties from physicians to non-physicians health care providers - is one of the effective approaches that has been used to address lack of human resources in Africa [24], including for management of HTN [25,26].. Considering the experience of the Mozambique’s NHS in task shifting in obsterics, surgery and mental health [14, 27],, we strongly believe that targeted context-specific changes to the Health System in Mozambique can also be done to allow task-shifting for the diagnosis and management of hyoertensive patients to occur, in order to improve rates of control and outcomes.
Limitations: Despite the acknowledging that the “snapshot” taken during one month cannot be fully representative of the situation, we believe that this description of hypertension care in ED constitutes an initial step towards addressing poor outcomes and understanding the organizational changes needed to improve care in our setting. Moreover, this model can be ameliorated and replicated for assessment of health care for other risk factors and NCD, thus supporting priority setting and selection of the most efficient interventions and health services changes that can be done to create of context-tailored NCD clinics in Africa.