Assessment of hypertension service availability in some primary health centres in Nigeria: a mixed-methods study

Abstract

Objective

Strengthening primary health centre (PHC) systems is a potentially effective strategy to reduce the burden of non-communicable diseases in Nigeria, a low/middle-income country with limited resources. The aim of this study was to assess hypertension service availability in some PHCs in Nigeria and seek recommendations that could facilitate improved services from PHC workers.

Design

Explanatory sequential mixed-methods study.

Settings

PHCs in the six geopolitical zones and Federal Capital City of Nigeria.

Participants

Eighteen PHC workers and 305 PHC facilities.

Method

Hypertension service availability and readiness were assessed in PHCs across Nigeria using a pro forma adapted from the WHO Service Readiness and Assessment tool. Eighteen workers in the PHCs were subsequently interviewed for in-depth exploration of hypertension service availability and readiness.

Findings

Among the 305 health facilities assessed, 96 (31.5%) were in urban, 94 (30.8%) in semiurban and 115 (37.7%) in rural local government areas. Majority of the health facilities (43.0%) were manned by community extension workers. Only 1.6% and 19.7% of the health facilities had physicians and pharmacy technicians, respectively. About 22.3% of the providers had training in hypertension in the last 1 year. All the PHCs lacked adequate supply of essential antihypertensive medications. The identified deficiencies were less common in the urban PHCs compared with others. Qualitative analysis showed that the personnel, essential facilities and medicines required to provide hypertension services in the PHCs were inadequate. Suggested recommendations to successfully provide these services were provision of performance-based incentives; adequate staffing and training; supportive supervision of staff; provision of adequate equipment and essential medicines for hypertension management; provision of conducive environment for clients; and community engagement and participation.

Conclusion

Majority of the PHCs are currently not adequately equipped to provide hypertension services. Addressing identified gaps and using suggestions provided will guarantee successful provision of effective services.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• This mixed-methods study allowed for in-depth exploration of views of primary health centre (PHC) workers on provision of hypertension services.

• The researchers physically verified availability and functionality of the facilities in the various PHCs.

• The finding of the study is generalisable.

• Socioeconomic disparities between the states that could have influenced the availability of hypertension services were not assessed.

Background

Non-communicable diseases (NCDs) account for about 75% of all deaths globally.¹ The 2018 WHO report showed that NCDs account for 75% of all premature adult deaths among economically productive age group of between 30 and 69 years in low/middle-income countries.² In Nigeria, NCDs account for 29% of all deaths, of which cardiovascular diseases (CVDs) account for 11%.²

One of the major risk factors for CVDs is hypertension. Hypertension has become a disease of public health importance due to its increasing prevalence, associated morbidity and mortality.^1–7 The WHO report showed that hypertension affects 1.28 billion adults aged 30–79 years globally.⁴ Awareness, treatment and control of hypertension are poor in low/middle-income countries.4 5 8 9 About 46% of adults with hypertension are unaware of their hypertensive state, and less than half of those diagnosed are treated.^{4 8 9} In a recent study done in Nigeria, the age-standardised prevalence of hypertension was 38.1%, only about 33% of the patients with hypertension received treatment and about 12% of those on treatment had optimal control.^{5 6} There has been an increase in hypertension-related hospitalisation and annual health cost over the years.^10–14

The health delivery system in Nigeria operates in three tiers: tertiary, secondary and primary. They are provided and funded by federal, state and local governments, respectively, through suboptimal budgetary allocation. Other sources of funding are out-of-pocket payments, health insurance and donor funds.¹⁵ Primary healthcare centres (PHC) operate at the community level and are expected to play a critical role in the control and prevention of hypertension as they are the first point of contact for patients.¹⁶ Presently, there are about 30 000 PHCs in Nigeria, majority of which are publicly run and not for profit. Most of the PHCs are run by nurses and community health workers.¹⁷

There are many challenges in the management of hypertension in the Nigerian health system that contribute to the high morbidity and mortality experienced. The scarcity of a properly trained workforce in the healthcare delivery systems across Nigeria is a major setback.¹⁸ Presently, hypertension is mainly managed in the secondary and tertiary referral health institutions. These institutions are already overburdened, and with the present exodus of healthcare personnel, especially doctors and nurses from Nigeria, there is likely to be a severe shortage of health professionals in the secondary and tertiary levels of care.^{19 20} The health delivery systems, especially the PHCs in Nigeria, are inadequately funded and poorly equipped.²¹ They also lack the capacity for hypertension management in terms of screening, diagnosis, treatment and follow-up.

The WHO Regional Framework for Integrating Essential Non-Communicable Diseases in Primary Health Care Services was developed as a guide to this effect. It recommended the strengthening of PHCs to respond to major NCDs like CVD and their risk factors, especially hypertension.^{22 23} In Nigeria, the National Multi-Sectorial Action Plan for the Prevention and Control of Non-Communicable Diseases (2019–2025) was launched in 2019 in line with the WHO recommendation.¹⁶ In line with the action plan, specifically focusing on hypertension, the Federal Ministry of Health partnered with WHO and with the National Primary Health Care Development Agency to introduce the National Hypertension Control Initiative Programme in 2020.²⁴ The initiative’s main objective is to expand hypertension screening and promote early detection and treatment of uncomplicated hypertension in PHCs across Nigeria.

The Centre for Disease Control has advocated for a team-based approach to diagnose and manage hypertension, involving non-physician healthcare workers in the process.²⁵ Similarly, the 2021 WHO guidelines on pharmacological treatment of hypertension recommend that non-physician health professionals manage uncomplicated hypertension.²⁶ The task shifting task sharing (TSTS) approach, as recommended by the WHO, and adopted in Nigeria in 2014 for essential services, has extended to NCD management with hypertension being foremost.²⁷ The TSTS policy for the management of NCDs in Nigeria, though drafted, is yet to be signed and launched for adoption. For a successful implementation of the TSTS, the healthcare workers must be trained for the diagnosis and management of uncomplicated hypertension under the supervision of the prescribing authority.²⁶

Previous reports have shown that a team-based approach and task sharing in hypertension diagnosis and management are associated with better hypertension control, reduction in the cost of care and complications associated with hypertension.²⁸ This approach will also reduce the number of patients with hypertension who will be managed at the secondary and tertiary healthcare levels. To manage hypertension effectively in the PHCs, a strong responsive approach is mandated. Well-equipped centres with basic technologies such as equipment and diagnostics, trained health workers, essential medicines and strong referral systems are necessary.

With this context in mind, we evaluated the availability of hypertension services in some existing PHCs in Nigeria.

Methodology

This was an explanatory sequential mixed-methods study that used both quantitative and qualitative data collection to assess hypertension service availability and readiness in some PHCs across Nigeria. The quantitative aspect revealed the scope of the problem and areas requiring intervention, while the qualitative component provided an in-depth understanding of health workers’ experiences with hypertension services, highlighting barriers, access issues, service strengths and weaknesses.

This study was conducted in Nigeria between August 2022 and January 2023. Nigeria is one of the countries in West Africa and has six geopolitical zones, 36 states and a Federal Capital Territory (FCT), which is Abuja. The estimated population of Nigeria in 2022 was 218 541 212.²⁹ It has a total of about 30 000 PHCs.¹⁷

Quantitative arm of study

Sample size calculation

The required sample size, n, is given as Zp(1−p)/e², and was determined using the formula for estimation of proportion with a specified precision and finite population correction for proportion (if small population),³⁰ where p is the proportion of PHCs with medicine and commodities for NCDs (11%)³¹ and e is the SE (5%). This gave a minimum sample of 123 health facilities after inclusion of 10% attrition rate.

Sampling technique

The study employed a multistage sampling method in the selection of the PHCs.

In stage 1, one state was selected from each geopolitical zone by simple random sampling technique, while the FCT was purposively selected giving a total of six states and the FCT. The FCT was purposively chosen because it is the capital of the country. The simple random sampling technique was applied to the other geopolitical zones to ensure that each state within a geopolitical zone stands an equal probability of being selected. Furthermore, the simple random sampling technique was employed because there was access to a complete list of member states of each geopolitical zone. The country’s six geopolitical zones consist of a fixed number of states from which a state was selected to represent the zone.

In stage 2, two local government areas (LGAs) were selected from each of these six states and the FCT through simple random sampling technique giving a total of 14 LGAs.

In stage 3, a total sampling of all the PHCs in the selected LGAs was done in this survey. In each PHC, the officer in charge (OIC) of the facility was interviewed and where that was not available, the next officer to the OIC was interviewed. The officer in charge was purposively chosen being the manager of the facility who can provide detailed information about the facility and the activities.

The sampling technique is shown as a flow chart in online supplemental figure.

Data collection tool

Quantitative data

The quantitative data were manually collected using a pro forma that was in the form of a checklist with structured sections for the data collection on information such as location of the PHC, OIC of the PHC, availability of a pharmacy technician, availability and functionality of equipment for providing hypertension services such as sphygmomanometer, glucometer, measuring tapes, urinalysis strips, lipid profile kit, weighing scales; availability of essential medications needed to manage hypertension based on essential medicine list; specific training on hypertension management in the past 1 year; and availability of specific services for hypertension care. This checklist was adapted from Service Availability and Readiness Assessment tool developed by the WHO to assess health facilities’ availability and readiness to diagnose and treat common medical problems.³² The researchers interviewed the OIC or the deputy in the selected PHCs. The availability of medications, equipment and functionality of the equipment were physically verified by the researchers.

Qualitative data

Sampling

Participants for the qualitative interview were purposively selected to ensure that they were the most appropriate to provide access to the type of knowledge sought by the qualitative component of the study. No prospective respondent refused to participate or opted out during the study. Key informant interviews were conducted with a total of 18 respondents, consisting of 6 males and 12 females from all six geopolitical zones and FCT. The interviewees were 3 directors, 1 deputy director, 3 PHC coordinators and 11 OICs of PHCs.

Questions and discussions during the interview were centred on the availability and adequacy of facilities such as sphygmomanometer, stethoscopes, weighing scales, glucometers and antihypertensive medications required to provide hypertension services; availability of personnel to provide hypertension services; possible positive and negative impact of availability of hypertension services at the PHC on patients, community and overall health system; barriers to provision of hypertension services in the PHCs; and recommendations to successfully provide efficient and effective hypertension services in PHCs in Nigeria (online supplemental material).

Data collection

Male and female physicians who had undergone training on qualitative research were involved in interviewing the prospective respondents. The interviewers were clinical researchers who had been practising clinical medicine as consultants. The intent of the study was clearly communicated to the prospective respondents before their recruitment and they were assured about ethical issues such as safety, confidentiality and freedom to opt out from the study at any stage without prejudice.

All interviewees had face-to-face interview except one that was done virtually. The average duration of the interview was about 15 min. The interviews were conducted in English language under a conducive environment devoid of distractions following previously scheduled appointments, and prompts were given as necessary. The interviews were audio-recorded and transcribed. There were no repeat interviews and further interview was discontinued after saturation was reached. The authors ensured that the recorded interviews were correctly transcribed by listening to the recorded interview and matching with the transcription multiple times. The transcriptions were also reviewed by the interviewee to ensure there was no misrepresentation, and feedback was obtained from them.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Data management

The data generated from the quantitative study, audio-recordings and electronic copies of transcripts were stored in Google Drive without any personal identifier to ensure confidentiality. The stored information had a password to limit access to only the lead researchers.

Data analysis

Quantitative data analysis

Quantitative data were imported from an online Excel sheet and analysed using IBM SPSS V.25.0 (IBM Corp). Bivariate analysis using Χ² was done to assess significant differences in staff availability and general service readiness of the PHCs by location. The level of significance was set at p<0.05.

Qualitative data analysis

Audio-recordings and electronic copies of transcripts were stored in Google Drive to ensure confidentiality and access to the researchers. The audio-recordings were transcribed using the transcription template for the study. The transcripts were reviewed by another group of researchers and transferred into ATLAS.ti V.9.0.22.0 to organise and sort for further data analysis. Two researchers read the transcripts for familiarisation and codebook development. The codebook was developed using a hybrid of inductive approach, that is, drawing from the qualitative data in the transcripts, and deductive approach, that is, drawing from the interview guide. The researchers coded the same transcripts to ensure that the codes were consistently applied if needed. Discrepancies were resolved through a consensus-building approach guided by the research objectives. Thereafter, ATLAS.ti output from different researchers was carefully reviewed through the intercoder reliability tool and later merged.

The transcripts were coded, thereafter quotations pulled together to understand pattern across the data. The analysis was guided by the study objective which was to assess hypertension service availability and readiness in some PHCs across Nigeria. The data analysis adopted a thematic and content analytical approach which was used to derive recurring themes and subthemes from the data. Four themes and 18 subthemes emerged from the qualitative data analysis (online supplemental table).

Results

Three hundred and five PHCs were assessed across all the geopolitical zones and the FCT of Nigeria in this study. The distribution showed that 68 (22.3%) were in southwest zone, 48 (15.7%) were in north central zone, 30 (9.8%) were in south-south zone, 34 (11.2%) were in northeast zone, 24 (7.9%) were in northwest zone, 18 (5.9%) were in southeast zone and 83 (27.2%) were in FCT (figure 1). Also, 96 (31.5%) were urban, 94 (30.8%) were semiurban and 115 (37.7%) were rural LGAs. Majority of the health facilities (43.0%) were manned by community extension workers, 33.1% by nurses and 22.3% by other groups of health workers besides doctors who worked in only 1.6% of the health facilities. Only about 19.7% of the health facilities had pharmacy technicians and just 22.3% of all cadres of health workers across the facilities have had training in hypertension (table 1).

Figure 1.

Map. FCT, Federal Capital Territory; PHCs, primary health centres.

Table 1.

Staff availability and general service readiness of studied primary health centres (PHCs)

Variable	Frequency (n=305)	Percentage
Location of PHC
Urban	96	31.5
Semiurban	94	30.8
Rural	115	37.7
Professional status of officers in charge
Doctor	5	1.6
Nurse	101	33.1
Community extension worker	131	43.0
Others*	68	22.3
Availability of pharmacy technician
Yes	60	19.7
No	245	80.3
Staff training in hypertension
Yes	71	22.3
No	234	76.7
Availability of national guidelines on hypertension
Yes	59	19.3
No	246	100
Clinic day for hypertension services
Yes	30	9.8
No	275	90.2

*Likelihood ratio.

On comparing staff availability and general service readiness by location of PHCs, statistically significant differences were found in distribution of the OIC of the PHCs. Nurses constituted 47.5% and 29.7% of the OIC of the urban and semiurban PHCs, respectively, compared with 22.8% that was seen in rural PHCs. Similarly, the community health extension workers (CHEWs) were majorly (54.2%) the OIC of the rural PHCs compared with 19.8% and 26% seen in the urban and semiurban PHCs, respectively (table 2).

Table 2.

Staff availability and general service readiness of primary health centre by location (N=305)

Variable	Urban n (%)	Semiurban n (%)	Rural n (%)	Total	P value
Professional status of officers in charge
Doctor	2 (40.0)	2 (40.0)	1 (20.0)	5 (100)
Nurse	48 (47.5)	30 (29.7)	23 (22.8)	101 (100)
Community extension worker	26 (19.8)	34 (26.0)	71 (54.2)	131 (100)	<0.001*
Others*	18 (26.5)	28 (41.1)	22 (32.4)	68 (100)
Availability of pharmacy technician
Yes	30 (50.0)	15 (25.0)	15 (25.0)	60 (100)	<0.004
No	68 (27.8)	78 (31.8)	99 (40.4)	245 (100)
Staff training in hypertension
Yes	21 (29.6)	16 (22.5)	34 (47.9)	71 (100)	<0.128
No	72 (30.8)	78 (33.3)	84 (35.9)	234 (100)
Availability of national guidelines on hypertension
Yes	17 (28.8)	8 (13.6)	34 (57.6)	59 (100)	<0.001
No	75 (30.5)	86 (35.0)	85 (34.5)	246 (100)
Clinic day for hypertension services
Yes	15 (50.0)	6 (20.0)	9 (30.0)	30 (100)	<0.049
No	78 (28.4)	87 (31.6)	110 (40.0)	275 (100)

*Likelihood ratio.

Furthermore, pharmacy technicians were mostly found in urban PHCs (50.0%) with significant difference across the PHCs (p<0.001). Additionally, there was a significant difference in clinic days for hypertension services (p<0.049), but no significant difference in staff training (p=0.129). On the other hand, national guidelines were more available in rural PHCs (57.6%) than in others, with the differences being statistically significant (p<0.001) (table 2).

Most of the PHCs did not have essential antihypertensive medications. The most commonly available medicines were nifedipine, amlodipine and methyldopa which were only present in 40.8%, 39.7% and 28.1% of the PHCs. Less than 15% of the PHCs had medications such as losartan, valsartan, bendroflumethiazide, hydralazine, atenolol, propranolol, labetalol and captopril (figure 2).

Figure 2.

Frequency of medications. HCT, hydrochlorothiazide.

A high percentage of the health facilities had diagnostic instruments such as sphygmomanometer: 95.8% in urban, 95.7% in semiurban and 88.7% in rural health facilities. However, a sizeable percentage of these instruments (23.5%) were not functional in the rural health facilities. Similarly, a high proportion of the semiurban (31.9%) and rural health facilities did not have a glucometer (46.1%). In addition, 44.3% of the rural health facilities did not have urine test kits compared with urban (10.4%) and semiurban (19.1%) health facilities. Although stethoscopes were frequently available across the health facilities, the functionality reduces across the health facilities by location, with about 4.3% non-functional stethoscopes in urban health facilities compared with 11.2% in semiurban and 19.2% in rural health facilities. Overall, the urban PHCs had more facilities for the management of hypertension compared with those in the semiurban and rural PHCs (table 3).

Table 3.

Availability and functionality of diagnostic instruments at PHCs by location (N=305)

Variable	Urban n (%)	Semiurban n (%)	Rural n (%)	Total
Sphygmomanometer availability
Available	92 (95.8)	90 (95.7)	102 (88.7)	284 (93.1)
Not available	4 (4.2)	4 (4.3)	13 (11.3)	21 (6.9)
Functionality n=284
Yes	87 (94.6)	78 (86.7)	78 (76.5)	243 (85.6)
No	5 (5.4)	12 (13.3)	24 (23.5)	41 (14.4)
Stethoscope availability
Available	94 (97.9)	89 (94.7)	102 (88.7)	285 (93.4)
Not available	2 (2.1)	5 (5.3)	13 (11.3)	20 (6.6)
Functionality n=285
Yes	90 (95.7)	79 (88.8)	82 (80.4)	251 (88.1)
No	4 (4.3)	10 (11.2)	20 (19.6)	34 (11.9)
Glucometer availability
Available	81 (84.4)	64 (68.1)	62 (53.9)	207 (67.9)
Not available	15 (15.6)	30 (31.9)	53 (46.1)	98 (32.1)
Functionality n=207
Yes	74 (91.4)	53 (82.8)	52 (83.9)	179 (84.5)
No	7 (8.6)	11 (17.2)	10 (6.2)	28 (13.5)
Weighing scale
Available	91 (94.8)	88 (93.6)	87 (75.7)	266 (87.2)
Not available	5 (5.2)	6 (6.4)	28 (24.3)	39 (12.8)
Functionality n=266
Yes	78 (85.7)	81 (92.0)	82 (94.3)	241 (90.6)
No	13 (14.3)	7 (8.0)	5 (5.7)	25 (9.4)
Test kit for urine
Available	86 (89.6)	76 (80.9)	64 (55.7)	226 (74.1)
Not available	10 (10.4)	18 (19.1)	51 (44.3)	79 (25.9)
Lipid profile kit
Available	40 (41.7)	32 (34.0)	7 (6.1)	79 (25.9)
Not available	56 (58.3)	62 (66.0)	108 (93.9)	226 (74.1)

PHCs, primary health centres.

Result of qualitative analysis

Theme 1: availability of health personnel, medical equipment, essential medicines and hypertension services in PHCs

Unavailability of full complement of health personnel

The PHCs did not a have full complement of health personnel such as doctors, nurses, pharmacy technicians, dental technicians and CHEWs. Most of the interviewees reported that there was a shortage of healthcare workers across the various departments in the PHC. They also reported that majority of the PHCs were headed by the CHEWs.

We are presently seriously short of staff. We need staff in all the departments because we are running shifts here and the shift is not as smooth as expected because of the shortage of staff. (female OIC, semiurban)

Inadequacy of supply of essential medicines

Majority of the interviewees reported the inadequate supply of essential antihypertensive medications. Some of the PHC workers usually buy some antihypertensive medications with their personal funds to make them available.

In most cases, essential medicine to treat hypertension are not readily available in the PHCs. They are not provided. Occasionally, the workers in the facility may decide to buy some antihypertensive medications in case of emergency situations like a patient coming with a blood pressure of 200/140mmHg. You need to do something, you don’t allow the patient to go. (female OIC, semiurban)

Inadequacy of basic medical equipment

Most interviewees reported that they have basic equipment like sphygmomanometers, glucometers, stethoscopes and weighing scales, but they were not adequate. However, it was revealed that some PHC workers spent their personal money to equip their facilities with equipment such as a sphygmomanometer. Some workers also use their personal equipment to provide services at their PHCs because the government did not provide them.

The sphygmomanometer is available, but I bought it with my money. There is no official one provided by the government. (male OIC, rural)

Absence of hypertension services

Interviewees provided mixed responses. While some offered some form of care, although limited, others did not provide hypertension services in their PHCs because they were not authorised to manage hypertension cases based on their level of training.

No, we do not manage hypertension. We refer them because we are currently not authorized to manage hypertensive case. (female OIC, semiurban)

Presence of limited hypertension services

A few of the PHCs that had the capacity in terms of skilled health personnel and facilities provided some level of hypertension services.

At PHC, most of our facilities are being equipped especially now that we operate under Basic Health Care Provision Fund. So, majority of the medicines have been provided for the facility because hypertension is one of the diseases they can handle to a certain level. So, to the limit of what the PHC can handle, we have supply for those drugs. (female OIC, urban)

Theme 2: benefits of provision of hypertension services in the PHCs

The interviewees reported some benefits that may accrue to patients with hypertension and overall health system if PHCs are empowered to provide basic hypertension services. The enumerated benefits by some of them were: improved access to care, reduced cost of healthcare, reduced workload at secondary and tertiary levels of care, prompt diagnosis of hypertension and improved hypertension management outcomes.

Improved access to care

Most interviewees also reported better access to care as one of the benefits of providing hypertension services at the PHCs. This is because the PHCs are in close proximity to the people in the community. Also, some of the PHC workers are members of the community and they are more likely to feel more comfortable accessing care from their health facility.

The service is always at their reach; they get easy access to the service and they will feel at home. (male OIC, rural)

Reduced cost of healthcare

Majority of the interviewees reported reduced cost of healthcare to the patients as one of the benefits of provision of hypertension services at the PHCs. These patients would not need to travel long distances to access the same service. The additional transport cost usually discourages some patients from accessing care in both secondary and tertiary health facilities.

It will reduce the cost of health care to the patient. (male OIC, rural)

Reduced workload at secondary and tertiary levels of care

Some interviewees reported reduced workload at both secondary and tertiary levels of care if adequate hypertension services are provided at the PHCs. This will also allow the health workers in these health facilities to have adequate time to attend to patients who have more complicated health problems and reduce their risk of being burnt out.

It reduces the workload in the secondary and tertiary health facilities. (male director, urban)

Early diagnosis of hypertension and improvement in patient outcomes

Some interviewees reported that provision of hypertension service at the PHCs will lead to early diagnosis, since they are closer to the patients especially at the community level compared with the secondary and tertiary health facilities. This will also lead to improvement in patient outcomes such as reduction in hypertension-related complications.

In the aspect of the patients, when hypertension is detected early, it is a very nice thing on the side of the patient because it will prevent them from coming down with complications such as heart attack, kidney issues and some other things. When it is detected early, adequate treatment that will be beneficial to the patient will be given. (male deputy director, semiurban)

Theme 3: drawback of provision of hypertension services in PHCs

Majority could not report drawbacks of provision of basic hypertension services to patients and the overall health system. However, a few reported poor management and poor outcome of patients if requisite training is not given and there is delayed referral.

The only drawback is when training and retraining is not done because the level of experience of the people working at the PHC is limited. For instance, if a patient presents with hypertensive crisis or very high blood pressure, medically, we are not allowed to crash it immediately, but if this people who don’t have that knowledge do that, it causes problem in some parts of the brain. (male director, urban)

Theme 4: recommendations for successful provision of hypertension services in PHCs

The recommendations were provision of medications, adequate staffing, even distribution of staff in PHCs, training and supportive supervision of staff, provision of adequate equipment and performance-based incentives, provision of conducive environment for workers and clients, and community engagement and participation.

Provision of medications

Most of the interviewees reported that the regular supplies of essential antihypertensive medications in the PHCs will improve hypertension service delivery. Some also reported that the medications should be significantly subsidised if they cannot be made available at no cost to the patients.

They should equip us with the medications we need to manage hypertension. If they cannot make it completely free, the cost of the medicines could be subsidized. (female OIC, semiurban)

Adequate staffing and even distribution of staff in the PHCs

Most of the interviewees reported the need to employ more staff across the PHCs for effective service delivery. They also reported that there should be a balance distribution of health workers based on the needs and capacities of the PHCs.

First, the government should make enough health workers available by recruiting more hands. Like we have about just 4 pharmacist technicians in the whole LG and we have about 22 health facilities. Other cadres like nurses, CHEWs are affected too, now we try to employ casual workers. (female OIC, semiurban)

Performance-based incentives for the PHC staff

Few of the interviewees reported that provision of performance-based incentives will motivate PHC workers to perform their duties effectively well and encourage others to be diligent.

They should recognize the people that are doing well and reward them in order to encourage others. (male OIC, rural)

Training and supportive supervision of the PHC workers

Most of the interviewees reported the fact that non-physician health workers do not have adequate knowledge on management of uncomplicated hypertension. They reported that there should be regular training and supportive supervision in order to successfully provide hypertension services in the PHCs.

There must be frequent and supportive supervision. (male OIC, rural)

Provision of equipment and conducive environment for PHC staff and clients

Some interviewees reported that the government should provide equipment required to manage hypertension in adequate numbers. Also, a few also reported that improvement of the structural facilities of the PHCs will encourage patronage by clients and job satisfaction among the service providers.

They should assess the centre to identify areas not conducive for the patient and staff and renovate them. (female OIC, urban)

Community engagement and participation

Some of the interviewees reported that for successful provision of hypertension services at the PHCs, the community must be part of the programme as stakeholders. This will be achieved by regularly engaging and involving them in the programme.

Involving the community in what we are doing, meeting stakeholders in the community, speaking to them and creating more awareness. (female OIC, semiurban)

Discussion

This study assessed the hypertension service availability in some PHCs in all the six geopolitical zones and FCT in Nigeria with the aim of identifying existing gaps in the health system. Recommendations that could facilitate successful provision of hypertension services were sought from some of the PHC workers. The study found that the majority of the PHCs did not have hypertension management guidelines. Most PHCs did not offer adequate hypertension services; they also lacked sufficient facilities and essential antihypertensive medications, and the complementary staff required to provide satisfactory hypertension services at the primary level of care.

The study found that about one-fifth of the PHCs have hypertension management guidelines while three-quarters of the OICs of the PHCs have not been trained in hypertension management. These identified gaps could adversely affect provision of quality care to clients with hypertension. The use of treatment guidelines and training are highly pivotal to successful TSTS in hypertension management. Previous reports emphasised the need for the training of non-physician health workers especially at the primary level of care for the successful management of hypertension.^{33 34} Gyamfi et al³³ reported significant improvement of knowledge and practice related to hypertension diagnosis and management, interpersonal skills and patient education of community health nurses following training. Labhardt et al³⁴ also reported significant improvement of hypertension and glycaemic control among those with hypertension and diabetes mellitus who were managed by non-health physicians after training.

This study found that the majority of the PHCs were not adequately staffed and only 10% of the PHCs have specific consultation day(s) for clients with hypertension. For instance, about 80% of the PHCs did not have pharmacy technicians whose services are pivotal to delivery of hypertension care in the primary level of care. Similarly, 43% of the OICs of the PHCs were community extension workers, 33.1% of the PHCs have nurses as OIC, while less than 2% had in-house physicians. The distribution of the health workers in the PHCs showed that the urban and semiurban PHCs had a significantly higher number of high and middle cadre health workers than the rural PHCs. The finding in this study is similar to the report by Willcox et al³⁵ that showed inadequate human resource for health in PHCs especially those in rural areas of sub-Saharan Africa. The limited hypertension service available was significantly more present in the urban PHCs (50%) compared with the semiurban PHCs (30%) and rural PHCs (20%). This may also be explained by the uneven distribution of more skilled healthcare workers in favour of the urban PHCs. The finding of only few physicians in the PHCs is similar to the report from a previous study in Iraq.³⁶ The possible reasons for few physicians in the PHCs in Nigeria include preference of physicians to work in tertiary hospitals, especially in the urban setting and the acute shortage of physicians in the country due to ongoing migration of Nigerian physicians out of the country.^{37 38} This situation may not change in the near future; hence, there is a need to effectively use the limited human resources for health by adopting the TSTS approach. According to the WHO recommendation, non-physician health workers are expected to complement physicians in managing uncomplicated hypertension at the primary care level and referring the complicated ones to higher-level facilities.³⁹

There was availability of some equipment such as sphygmomanometers, stethoscopes and weighing scales required to manage hypertension in over 90% of the PHCs. However, some of this equipment was procured with personal funds by the PHC workers because the government did not provide it. Surprisingly, about one-third of the PHCs did not have some basic investigative tools such as urinalysis strips and glucometers that are essential in the management of uncomplicated hypertension. The finding of this study is similar to the report of Oyekale²¹ that showed that about one-third of the PHCs assessed in 12 states of Nigeria did not have functional sphygmomanometer and stethoscopes.

All the PHCs studied lack the majority of antihypertensive medications that are under the essential medication list in Nigeria. This finding is similar to reports from previous studies.^{21 40 41} Oyekale²¹ reported that most of the essential drugs were not available in the PHCs in 12 states of Nigeria across the six geopolitical zones, while Orji et al⁴⁰ reported that about 60% of the PHCs had 30-day zero regimen of any of the antihypertensive medications in stock. Droti et al⁴¹ also reported that there was poor availability of essential medicines in sub-Saharan countries especially at PHC facilities. This development is quite unsatisfactory as availability of essential medications remains a mirage in most African countries including Nigeria. This has been ongoing for more than three decades after the Bamako Initiative was signed by African leaders. The primary objective of the initiative was to make essential medications readily available to the people in African countries.⁴²

With the relative unavailability of the hypertension services in terms of adequate number of equipment, essential antihypertensive medications and complimentary staff as highlighted in this study, the Nigerian government and other stakeholders have been working arduously to create and adopt suitable guidelines and to implement policies on hypertension care particularly in terms of availability at the primary healthcare level.

There are ongoing efforts by the government to improve the structure of the primary healthcare facilities so that they are adequately equipped to diagnose and treat hypertension. The link between primary care providers and specialists is being strengthened so that patients with more complex health problems can receive the appropriate level of care when referred. Efforts are also being made to ensure that there are enough qualified staff to meet the demands of the population by training non-physician health workers in hypertension diagnosis and management.^{43 44} It is worth noting that the national guideline for the management of hypertension in Nigeria has been formulated according to WHO guidelines.²⁶ The guidelines have components that take all the issues discussed into consideration and are currently awaiting ministerial approval. Finally, the Nigerian government has committed itself to increasing the funds for primary healthcare and also leveraging external funding from donors to support their efforts.⁴⁵ This is very crucial in ensuring that these policies and guidelines are effectively implemented.

The recommendations by the PHC workers to improve hypertension service availability in the PHCs were training of non-physician health workers in management of hypertension; monitoring and evaluation of the hypertension programme; community engagement and participation in the health programmes offered by the PHCs; provision of conducive environment for clients; provision of adequate equipment and medications required to manage uncomplicated hypertension; provision of performance-based incentives for PHC workers involved in the hypertension programme; and employment of more staff to adequately cover the PHCs.

The limitation of this study includes the fact that the influence of socioeconomic disparities between the states in the various geopolitical zones, which could have influenced the availability of hypertension services in the health facilities, was not assessed. However, the study has some strengths which include the fact that it employed a mixed-methods approach which allowed for an in-depth exploration of views of some critical stakeholders such as the PHC coordinators and OIC on provision of hypertension services in their centres. The researchers did not rely on reports of the OIC for assessment of the facilities, but the availability and functionality of the equipment such as glucometer, sphygmomanometer, weighing scales and medications were physically assessed in the PHCs. In addition, the study assessed 305 PHCs in the country that spread in all the six geopolitical zones; hence, the finding of this study is generalisable.

In conclusion, the study found that the majority of the PHCs did not offer adequate hypertension services; they also lacked sufficient facilities, essential antihypertensive medications and complementary staff required to provide satisfactory hypertension services at the primary level of care. The PHC workers were highly motivated to provide hypertension services if the identified challenges are addressed by following their recommendations.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Obtained.

Ethics approval

This study involves human participants and ethical approval was obtained from the National Health Research Ethics Committee of Nigeria, Federal Ministry of Health, Abuja, Nigeria. The approved protocol reference was NHREC/01/01/2007-16/09/2022. Participants gave informed consent to participate in the study before taking part.