ABSTRACT
Background and Aims
Hypertension is becoming a major public health issue in Ethiopia. However, there is limited comprehensive evidence on hypertension care, including service availability, utilization, and care quality. This study aimed to determine the effect of the NORAD‐WHO‐NCD intervention in improving the availability, utilization, and quality of hypertension care in public healthcare facilities.
Methods
A multicenter, quasi‐experimental study comprising 31 interventions and 62 control public healthcare facilities was conducted across Ethiopia's six regions and one city administration between November 12 and December 31, 2023. A data abstraction form was used to collect relevant data spanning 54 months from various departments. To determine the independent effects of the intervention, a differences‐in‐difference regression model was used and p < 0.05 was used to indicate statistical significance.
Results
From 2019 to 2023, the percentage of healthcare facilities treating hypertension increased to 93.6% for intervention facilities and 90.3% for control facilities. The average monthly number of screenings performed in 2023 was 682 (95% CI 592, 772) among intervention and 278 (95% CI 238, 318) among control health facilities. In 2023, the average monthly number of newly diagnosed patients was 6 (95% CI 5, 7) by intervention and 4 (95% CI 3, 5) by control health facilities. Similarly, the average monthly number of patients receiving pharmacologic treatment was 138 (95% CI 103, 173) in intervention and 49 (95% CI 41, 57) in control facilities. In the intervention and control facilities, the average monthly number of patients with controlled blood pressure was 121 (95% CI 89, 154) and 49 (95% CI 40, 58), respectively. The intervention led to a monthly average increase of 425 hypertension screenings across all age groups (95% CI 131, 719, p = 0.04).
Conclusions
While intervention facilities showed notable improvements, hypertension care services remain limited nationwide, underscoring the need for scalable interventions to address regional disparities.
Keywords: difference in difference model, Ethiopia, hypertension care, noncommunicable diseases, primary healthcare, quasi‐experimental study
Summary
- What is already known about this topic?
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◦Previous studies documented the community‐based and facility‐based prevalence and risk factors of hypertension in Ethiopia.
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◦The self‐care practices of hypertensive patients were documented among patients attending chronic follow‐up clinics in public and private health facilities.
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- What does this study add?
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◦This study is a comprehensive evaluation of the availability, utilization, and quality of hypertension care by determining the facility's service readiness, trained human resources availability, equipment availability, and medication availability in the health facilities.
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◦This study will show the current status, trend, and progress of hypertension screening, diagnosis, treatment, and control over the last 4 years and 6 months in selected regions of Ethiopia.
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- How this study might affect research, practice, or policy?
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◦The findings of this study will provide evidence for relevant stakeholders, the Federal Ministry of Health, regional health bureaus, and other partners involved in increasing and improving access to integrated quality healthcare services for hypertension and other NCDs in Ethiopia.
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◦It will present the real implementation of the hypertension care service in the country, as well as how to improve and decentralize hypertension care services.
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1. Introduction
Hypertension, a leading cause of death and disability worldwide, affects over 1.4 billion people and continues to rise, particularly in low‐ and middle‐income countries (LMICs) [1]. Hypertension is a significant contributing factor to many chronic conditions, such as coronary heart disease, stroke, heart failure, kidney disease, and others [2]. By 2025, hypertension is expected to affect 1.56 billion people worldwide, with developing countries accounting for two‐thirds of all cases [1].
This global burden is mirrored in Ethiopia, where hypertension poses a growing public health challenge. In Ethiopia, a systematic review found that the pooled prevalence of hypertension was 20.63% [3]. Another systematic review reported that general population‐based studies revealed the prevalence of hypertension from 9.3% to 30.3% and hospital‐based studies revealed 13.2% to 18.8%. Urban residents consistently exhibit higher prevalence rates, highlighting potential disparities in lifestyle, access to care, and awareness [4]. The national STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) survey in 2015 reported that the prevalence of raised blood pressure was 16% and the percentage of those taking medication for raised blood pressure was 4.8% [5].
The Ethiopian government has launched several initiatives to address the growing burden of hypertension and other noncommunicable diseases (NCDs). The Ministry of Health (MOH) launched the national strategic plan for the prevention and control of major NCDs in 2020 [6]. To achieve this strategic plan, the MOH and donors implemented innovative interventions to improve access to screening, care, and treatment of hypertension and other NCDs at all levels of the public health system. The Government of Norway, as part of its framework agreement with the World Health Organization (WHO) in development cooperation, has provided additional funding to WHO to address NCD and mental health in Ethiopia.
The focus is ensuring that NCD services, including hypertension, reach all those in need, employing relevant policy measures, and implementing people‐centered NCD services district by district to achieve comprehensive coverage of the at‐risk population. The Norwegian Agency for Development Cooperation (NORAD)‐WHO‐NCD services initiative [7] strengthens collaboration between the MOH and WHO, with a focus on increasing and improving access to quality healthcare services for hypertension, diabetes, and cervical cancer.
To ensure the success of the NORAD project, corrective actions should be implemented through monitoring and evaluation programs based on scientific and high‐quality standards. This mid‐term evaluation aimed to determine the effect of the NORAD‐WHO‐NCD intervention in improving the availability, utilization, and quality of hypertension care in selected Ethiopian PHC facilities.
2. Methods
2.1. Study Setting and Period
Ethiopia has an estimated 128 million people, making it the world's 13th most populous country and Africa's second most populous after Nigeria [8]. Currently, Ethiopia has 12 regional states and 2 city administrations, making up the federal structure [9]. Ethiopia's healthcare system consists of three levels: primary, secondary, and tertiary care. The primary healthcare unit (PHCU), including health posts, health centers, and primary hospitals, forms the backbone of NCD service delivery. The secondary healthcare system includes a general hospital that serves as a referral hub for other hospitals. In contrast, the tertiary healthcare system encompasses specialty hospitals and general hospital referral centers [10].
The NORAD initiative has been implemented in six regions and one city administration since 2020. This midterm evaluation was conducted in selected intervention and control public health institutions across the six regions and one city administration: Central Ethiopia, Amhara, Afar, Benishangul, Oromia, Somali, and Addis Ababa city administration. The study period ranges from January 1, 2019 to June 30, 2023, with data abstraction taking place from November 12, 2023 to December 31, 2023.
2.2. Study Design
A multicenter, quasi‐experimental study was conducted at selected public health facilities across six regions and one city administration and reported according to the REporting of studies Conducted using Observational Routinely‐collected Data (RECORD) statement (Supporting Information S1: Supplementary File 1: Data Abstraction Checklist).
2.3. Study Population
The study population includes both NORAD intervention‐implementing facilities and non‐implementing neighboring facilities. The study population included NORAD‐WHO‐NCD project health facilities and nearby districts. There were two control facilities for each NORAD‐WHO intervention (intervention facilities), but neither the project nor the partner provided further NCD‐related service to them other than the routine service the facilities were running after 2018 (control facilities). If fewer than two controls were available in a district, we included facilities from the nearest district in the same region. If there were more than two potential controls, we randomly selected two.
2.4. Sample Size Determination
Although initially planned to include 120 facilities, security and accessibility issues reduced the final sample to 93 facilities (31 intervention and 62 control). Replacement facilities that met the inclusion criteria could not be identified in the affected regions, while intervention and control facilities were distributed throughout the regions and districts.
In terms of the total number of health facilities allotted across the region, Central Ethiopia had 6 intervention and 12 control facilities, totaling 18 health facilities. Similarly, the regions of Oromia, Afar, Benishangul Gumuz, and Addis Ababa city administration each had 5 intervention and 10 control facilities, for a total of 15/region.
Finally, the Amhara region had three intervention and six control facilities, bringing the total number of health facilities to nine, while the Somali region had two intervention and four control facilities, for a total of six. If the district has fewer than two control facilities, we include those from the neighboring district in the same area until two control facilities are reached. However, if a district had more than two viable control facilities, we selected two randomly.
2.5. Selection of NORAD Project Intervention Facilities
The MOH, with input from regional health bureaus, selected facilities in six regions and one city administration based on expert recommendations. Each region included a mix of primary hospitals and health centers from selected districts. In Addis Ababa, five health centers were selected from two subcities to participate in the project's implementation. Similarly, in Amhara, Oromia, Central Ethiopia, and Benishangul, one primary hospital and five health centers were chosen from two districts each.
2.6. Operational Definitions
Core antihypertensive drugs: the simultaneous availability of three classes of drugs in the health facility: long‐acting dihydropyridine calcium channel blockers (CCBs) such as amlodipine 5 mg/10 mg or nifedipine 20 mg, thiazide diuretics such as hydrochlorothiazide 25 mg, and angiotensin‐converting enzyme (ACE) inhibitors such as enalapril 5 mg/10 mg or lisinopril 10 mg [11].
Core cardiovascular drugs: the simultaneous availability of three classes of drugs in the health facility: aspirin, beta‐blockers, and statins [11]. Core antihypertensive drugs ensure consistent hypertension management, while core cardiovascular drugs address broader cardiovascular risks.
Hypertension was defined as having a mean systolic blood pressure (SBP) of at least 140 mmHg and/or a mean diastolic blood pressure (DBP) of at least 90 mmHg or reporting the use of antihypertensive medications [11].
Intervention (NORAD‐WHO‐NCD intervention) is the initiative that supports the MOH in decentralizing NCD care from hospitals to local health centers through a process known as task‐shifting. This support includes providing additional medical equipment, necessary pharmaceuticals for hypertension care, relevant treatment guidelines, training health workers involved in comprehensive NCD care, supportive supervision, and periodic review meetings for quality assurance.
Control (routine intervention): this includes routine support from the Federal Ministry of Health and regional health bureaus for facilities to provide routine health services, including NCD care. Since 2018, these control facilities have received no NCD‐related support from the NORAD‐WHO‐NCD project or any other partner except the regional and MOH.
2.7. Data Collection Instrument and Process
Following a review of the relevant literature [12, 13, 14, 15, 16, 17, 18, 19], data were collected using a standardized abstraction checklist divided into three sections: service readiness, hypertension care, and resource availability. The Kobo toolbox was used to create facility profiles, and chronic follow‐up clinics provided longitudinal data. In contrast, the 54‐month‐measured variables (from January 2019 to June 2023) were initially collected on paper. The form aggregates the total number of required requests monthly, measuring each variable 54 times to understand the overall data pattern and track the progress of hypertension screening, early detection, and treatment over time (Supporting Information S2: Supplementary File 2).
Data were gathered by 19 experts with bachelor's degrees in health‐related fields who work in the zonal health office and healthcare facilities, as well as 7 experienced supervisors with master's and doctoral degrees in public health. Throughout the study, the chronic follow‐up clinic coordinators and NCD focal persons provided the data collectors with the necessary registration logbooks and other data sources. Training was given to data collectors and supervisors on the contents of the data abstraction checklist and how to abstract data from registration logbooks and chronic follow‐up clinics for 3 days before the data collection period by the research team.
2.8. Data Quality Assurance
To ensure data quality, a well‐designed data collection tool was created before the actual data collection procedure. A pretest was carried out 2 days before the actual data collection period at one health center in Addis Ababa, but this facility was not included in the final data collection process. The pretest objectives were to ensure clarity, familiarity with data abstraction checklists and data sources, and the availability of key variables in registration logbooks, chronic follow‐up clinics, and hypertension cohort registration forms. The regional supervisors provided strict supervision, discussing any issues that arose during data collection and taking corrective action as necessary.
2.9. Data Management and Analysis
The collected data were coded and checked for consistency and completeness up to the end of each data collection period. The data were entered into Microsoft Excel by three independent data encoders. Before the actual data cleaning and analysis, 20% of the collected data were double‐entered randomly to check for data entry errors. Finally, the data set was exported to STATA software version 17 for Windows. For numeric variables, descriptive statistics were expressed as the mean with a 95% confidence interval (CI), whereas frequency and percentages were used for categorical variables.
To assess the impact of intervention, the four components of the hypertension service delivery were presented to intervention and control facilities. We also evaluated the availability of medications and medical equipment, as well as the quality of care. The components were compared between facilities that did not implement the NORAD intervention and those that did. The Difference‐in‐Difference (DID) statistical model was used to analyze the intervention effect. The DID model accounts for preexisting differences between groups, isolating the effect of the NORAD‐WHO intervention by comparing changes in outcomes over time. It helps to isolate the specific effects of the NORAD project interventions by accounting for any preexisting differences between the two groups. The model assumes that the necessary data were collected using a well‐structured data collection form. DID requires data from both a treated group (those exposed to the intervention) and a control group. A p < 0.05 was used to indicate statistical significance.
3. Results
3.1. Health Facility Profiles
A total of 93 health facilities (31 intervention and 62 control facilities) were involved in this study, making the response rate 91.2%. Among the 93 public health facilities that took part in the study, 58 (62.4%) were in urban areas, and 35 (37.6%) were located in rural areas. In terms of facility type, there were 47 (50.5%) public health centers without physicians, equivalent to 34 (54.8%) control health facilities and 13 (41%) intervention health facilities (Table 1).
Table 1.
The distribution of public health facilities that were involved in this study by region and facility type (n = 93 health facilities).
| Facility profile | Categories | Intervention status | Total (n = 93) | |
|---|---|---|---|---|
| Intervention facilities (n = 31) | Control facilities (n = 62) | |||
| Frequency (%) | Frequency (%) | Frequency (%) | ||
| Location of region | Central Ethiopia region | 6 (19.4%) | 12 (19.4%) | 18 (19.4%) |
| Addis Ababa | 5 (16.1%) | 10 (16.1%) | 15 (16.1%) | |
| Afar region | 5 (16.1%) | 10 (16.1%) | 15 (16.1%) | |
| Benishangul‐Gumuz region | 5 (16.1%) | 10 (16.1%) | 15 (16.1%) | |
| Oromia region | 5 (16.1%) | 10 (16.1%) | 15 (16.1%) | |
| Amhara region | 3 (9.7%) | 6 (9.7%) | 9 (9.7%) | |
| Somali region | 2 (6.5%) | 4 (6.5%) | 6 (6.5%) | |
| Location of the facility | Urban | 22 (71%) | 36 (58.1%) | 58 (62.4%) |
| Rural | 9 (29%) | 26 (41.9%) | 35 (37.6%) | |
| Type of facility | Health centers without a physician | 13 (41.9%) | 34 (54.8%) | 47 (50.5%) |
| Health centers with a physician | 14 (45.2%) | 21 (33.9%) | 35 (37.6%) | |
| Primary hospital | 4 (12.9) | 7 (11.3%) | 11 (11.9%) | |
The availability of screening, early detection, and treatment services for hypertension had significantly improved for intervention facilities compared to controls between 2019 and 2023. There has been an increase in the proportion of intervention health facilities offering the services from 64.5% to 93.6%. The availability of national or WHO treatment guidelines for hypertension significantly increased between 2019 and 2023.
The number of facilities having either of these guidelines for treating hypertension has increased from 21 (67.7%) in 2019 to 30 (96.7%) in 2023, and this difference was found to be statistically significant (p < 0.05) (Table 2).
Table 2.
Availability of hypertension care service and human resource profiles of the selected health facilities, Ethiopia (n = 93 health facilities).
| Service type | Intervention status | January 2019 n (%) | June 2023 n (%) | p a |
|---|---|---|---|---|
| Average number of trained staff, mean (±SD) | 2 ± 1 | 2 ± 2 | ||
| Screening, early diagnosis, and treatment services availability | Intervention facilities | 20 (64.5) | 29 (93.6) | 0.005* |
| Control facilities | 51 (82.3) | 56 (90.3) | ||
| Written treatment guidelines availability (National or WHO) | Intervention facilities | 21 (67.7) | 30 (96.7) | 0.002* |
| Control facilities | 40 (64.5) | 49 (79.0) | ||
| Number of health facilities having trained staff | Intervention facilities | 18 (58.1) | 31 (100) | < 0.001** |
| Control facilities | 30 (48.4) | 39 (62.9) | ||
| Profession of the trained staff (for intervention and control facilities) | Health officer | 31 (43.1) | 46 (40.4) | 0.63b |
| Nurse | 23 (31.9) | 42 (36.8) | ||
| Physician | 18 (25.0) | 26 (22.8) | ||
| Total trained staff | 72 (100) | 114 (100) | ||
Abbreviation: SD, standard deviation.
This is the p value for the Pearson χ 2 test.
This is the p value for the likelihood‐ratio χ 2 test.
p < 0.05;
p < 0.001.
3.2. Availability of Hypertension Care Services
Screening for hypertension among all ages, including those between 18 and 39 and those above 40, reveals that intervention facilities screened more clients for hypertension compared to the control facilities. In 2019, the average number of people screened for hypertension monthly among intervention health facilities was 97 (95% CI 71, 122) (Table 3). From 2021 to 2023, the trend of the hypertension service provision in intervention and control facilities showed that intervention facilities outperformed control facilities. This included screening for hypertension among all age groups, newly diagnosed hypertensive patients, hypertensive patients who were being treated, and hypertensive patients whose blood pressure was controlled (Figure 1).
Table 3.
National average monthly hypertension screening, diagnosis, and treatment between 2019 and 2023 in selected public health facilities stratified by their intervention status (n = 93 health facilities).
| Variables | Intervention status | The mean value is compared with the 95% confidence interval estimates | ||||
|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | ||
| Mean (95% CI) | Mean (95% CI) | Mean (95% CI) | Mean (95% CI) | Mean (95% CI) | ||
| Hypertension screening among all ages per month | Intervention | 97 (71, 122) | 245 (161, 330) | 400 (318, 483) | 586 (516, 657) | 682 (592, 772) |
| Control | 133 (79, 186) | 169 (138, 201) | 190 (164, 216) | 227 (203, 215) | 278 (238, 318) | |
| Hypertension screening among 18–39 years of age per month | Intervention | 43 (29, 58) | 108 (66, 151) | 154 (123,185) | 258 (225, 291) | 348 (299, 398) |
| Control | 56 (39, 72) | 70 (56, 84) | 85 (72, 98) | 101 (90, 113) | 118 (100, 136) | |
| Hypertension screening among ≥ 40 years of age per month | Intervention | 54 (42, 66) | 137 (87, 188) | 250 (190, 310) | 345 (297, 393) | 354 (304, 404) |
| Control | 81 (39, 122) | 101 (82, 120) | 113 (98, 128) | 129 (116, 144) | 162 (138, 186) | |
| Newly diagnosed hypertensive patients per month | Intervention | 2 (1, 2) | 5 (3, 7) | 6 (5, 8) | 7 (6, 9) | 6 (5, 7) |
| Control | 1 (1, 2) | 2 (2, 3) | 2 (2, 3) | 3 (3, 4) | 4 (3, 5) | |
| Hypertensive patients on pharmacologic treatment per month | Intervention | 7 (5, 9) | 39 (29, 49) | 94 (76, 112) | 109 (89, 128) | 138 (103, 173) |
| Control | 14 (10, 18) | 24 (19, 28) | 34 (29, 38) | 38 (33, 43) | 49 (41, 57) | |
| Hypertensive patients with controlled blood pressure per month | Intervention | 4 (3, 5) | 30 (21, 38) | 82 (60, 105) | 92 (75, 109) | 121 (89, 154) |
| Control | 7 (5, 9) | 14 (12, 17) | 28 (24, 32) | 36 (31, 41) | 49 (40, 58) | |
Abbreviation: CI, confidence interval.
Figure 1.
Graphical diagnostic for the parallel trends and average number of clients screened for hypertension (A), newly diagnosed hypertensive patients (B), hypertensive patients on pharmacologic treatment (C), and hypertensive patients with controlled blood pressure (D) per month (n = 93 health facilities).
3.3. Equipment and Medication Availability
The availability and functionality of blood pressure apparatus and stethoscopes in both intervention and control facilities show a significant increase in the number of available equipment pieces. In 2023, both intervention and control facilities had eight functional blood pressure apparatuses on average (95% CI 7, 9) per month. It is noteworthy that the availability of the International Society of Hypertension (ISH) chart was found to be comparable in both intervention and control facilities (Table 4).
Table 4.
The number of available and functional medical equipment during 2019 and 2023 in selected public health facilities stratified by their intervention status (n = 93 health facilities).
| Variables | Intervention status | 2019 | 2020 | 2021 | 2022 | 2023 |
|---|---|---|---|---|---|---|
| Mean (95% CI) | Mean (95% CI) | Mean (95% CI) | Mean (95% CI) | Mean (95% CI) | ||
| Available blood pressure apparatus per month | Intervention | 9 (8, 10) | 10 (9, 11) | 11 (10, 12) | 12 (11, 13) | 12 (11, 13) |
| Control | 8 (7, 9) | 9 (8, 9) | 10 (9, 10) | 10 (9, 11) | 10 (9, 12) | |
| Functional blood pressure apparatus per month | Intervention | 6 (5, 7) | 7 (6, 8) | 7 (7, 8) | 8 (7, 8) | 8 (7, 9) |
| Control | 7 (6, 7) | 7 (6, 7) | 8 (7, 8) | 8 (7, 9) | 8 (7, 9) | |
| Available stethoscopes per month | Intervention | 7 (7, 8) | 8 (8, 9) | 10 (9, 11) | 9 (9, 10) | 10 (9, 10) |
| Control | 7 (7, 8) | 8 (7, 8) | 8 (8, 9) | 8 (8, 9) | 9 (8, 10) | |
| Functional stethoscopes per month | Intervention | 6 (5, 6) | 7 (6, 7) | 8 (7, 8) | 8 (7, 8) | 8 (8, 9) |
| Control | 6 (6, 7) | 7 (6, 7) | 7 (6, 8) | 7 (6, 8) | 7 (7, 8) | |
| Available ISH charts per month | Intervention | 1 (1, 1) | 1 (1, 1) | 1 (1, 1) | 1 (1, 1) | 1 (1, 1) |
| Control | 1 (1, 1) | 1 (1, 1) | 1 (1, 1) | 1 (1, 1) | 1 (1, 1) |
Abbreviations: CI, confidence interval; ISH, International Society of Hypertension.
The availability of thiazide diuretics, ACE inhibitors, and statins was significantly different between the intervention and control facilities. Intervention facilities were found to have these medications more of the time than their counterpart control facilities. In 2019, core antihypertensive medications were available only in 26.6% of the months in the intervention facilities, compared to 40.5% of the months in the control health facilities. However, in 2023, the availability of core antihypertensive medications improved to 58.6% in the intervention facilities and 51.9% in the control facilities (p < 0.05). In 2023, the availability of core cardiovascular medications improved to 18.5% in the intervention facilities and to 20.8% in the control facilities (p < 0.05) (Table 5).
Table 5.
Availability of medications for hypertension, CVDs, and diabetes mellitus in the years 2019 and 2023 in selected public health facilities stratified by their intervention status (n = 93 health facilities).
| Availability of medications per month | Drug availability | 2019 | 2023 | ||||
|---|---|---|---|---|---|---|---|
| Intervention facilities | Control facilities | p a | Intervention facilities | Control facilities | p a | ||
| Number of months (%) | Number of months (%) | Number of months (%) | Number of months (%) | ||||
| Calcium channel blockers | Yes | 123 (66.1) | 426 (70.5) | 0.26 | 163 (89.6) | 305 (87.6) | 0.51 |
| No | 63 (33.9) | 178 (29.5) | 19 (10.4) | 43 (12.4) | |||
| Thiazide diuretics | Yes | 121 (66.6) | 349 (59.4) | 0.07 | 142 (85.0) | 233 (65.8) | < 0.001** |
| No | 60 (33.2) | 239 (40.7) | 25 (14.9) | 121 (34.2) | |||
| ACE inhibitors | Yes | 100 (67.1) | 334 (58.8) | 0.06 | 136 (78.2) | 238 (68.4) | 0.02* |
| No | 49 (32.9) | 234 (41.2) | 38 (21.8) | 110 (31.6) | |||
| Core antihypertensive medications | Yes | 59 (26.6) | 253 (40.5) | < 0.01** | 109 (58.6) | 187 (51.9) | 0.14 |
| No | 163 (73.4) | 372 (59.5) | 77 (41.4) | 173 (48.1) | |||
| Aspirin | Yes | 56 (41.8) | 257 (45.6) | 0.43 | 85 (61.6) | 177 (53.6) | 0.11 |
| No | 78 (58.2) | 307 (54.4) | 53 (38.4) | 153 (46.3) | |||
| Statin | Yes | 36 (18.8) | 74 (13.1) | 0.06 | 64 (39.5) | 77 (24.6) | < 0.001** |
| No | 156 (81.3) | 490 (86.9) | 98 (60.5) | 236 (75.4) | |||
| Core cardiovascular medications | Yes | 24 (12.1) | 62 (10.5) | 0.55 | 31 (18.5) | 70 (20.8) | 0.53 |
| No | 175 (87.9) | 526 (89.5) | 137 (81.6) |
266 (79.2) |
|||
Abbreviations: ACE, angiotensin‐converting enzyme; CVDs, cardiovascular diseases.
This is the p value for the Pearson χ 2 test.
p < 0.05;
p < 0.001.
3.4. Quality of Hypertension Care
Intervention facilities, which have a larger number of trained healthcare professionals capable of treating hypertension, as well as adequate functional medical equipment and medication availability, outperformed control facilities in terms of screening, diagnosing, treating, and controlling high blood pressure (Table 6).
Table 6.
Quality of care for hypertension care service in 2019 and 2023 in selected public health facilities stratified by their intervention status (n = 93 health facilities).
| Quality measurement | Indicator | Category | 2019 | 2023 | ||
|---|---|---|---|---|---|---|
| Intervention facilities | Control facilities | Intervention facilities | Control facilities | |||
| Frequency (%) | Frequency (%) | Frequency (%) | Frequency (%) | |||
| Input | Availability of trained human resources capable of treating hypertension (in number) | General practitioner | 12 (13.9) | 25 (19.7) | 22 (13.7) | 32 (17.5) |
| Health officer | 27 (31.4) | 42 (33.1) | 52 (32.3) | 52 (28.4) | ||
| Nurse | 28 (32.6) | 29 (22.8) | 55 (34.2) | 57 (31.2) | ||
| Midwife | 19 (22.1) | 31 (24.4) | 32 (19.9) | 42 (22.9) | ||
| Total trained staff | 86 (100) | 127 (100) | 161 (100) | 183 (100) | ||
| Number of functional items, mean (95% CI) | Blood pressure cuff | 6 (5, 7) | 7 (6, 7) | 8 (7, 9) | 8 (7, 9) | |
| Stethoscope | 6 (5, 6) | 6 (6, 7) | 8 (8, 9) | 7 (7, 8) | ||
| Process | Medication availability | Core antihypertensive | 59 (26.58) | 253 (40.48) | 109 (58.6) | 187 (51.9) |
| Core cardiovascular | 24 (12.06) | 62 (10.54) | 31 (18.5) | 70 (20.8) | ||
| Output | Hypertension screening among all ages (mean with 95% CI) | 97 (71, 122) | 133 (79, 186) | 682 (592, 772) | 278 (238, 318) | |
| Newly diagnosed hypertensive patients (mean with 95% CI) | 2 (1, 2) | 1 (1, 2) | 6 (5, 7) | 4 (3, 5) | ||
| Hypertensive patients on treatment (mean with 95% CI) | 7 (5, 9) | 14 (10, 18) | 138 (103, 173) | 49 (41, 57) | ||
| Hypertensive patients with controlled BP (mean with 95% CI) | 4 (3, 5) | 7 (5, 9) | 121 (89, 154) | 49 (40, 58) | ||
Abbreviations: BP, blood pressure; CI, confidence interval.
3.5. Data Accuracy and Reporting Rates
The District Health Information System 2 (DHIS II) and monthly data gathered from each facility record (patient file or registry) during the survey were compared in this study. In the intervention health facilities, the percentage of accurate records of all patients assessed for hypertension rose from 6.6% in 2020 to 45% in 2023. Likewise, the accurate records of the control health facilities increased from 19% in 2020 to just 36.1% in 2023. Between 2020 and 2023, the percentage of overreporting in intervention facilities increased little, from 27.9% to 30.5%, while the percentage of control facilities increased somewhat, from 22.3% to 42%. Conversely, underreporting decreased significantly in both intervention (−41.1%) and control facilities (−36.8%).
From January 2019 to June 2023, we examined 54 months for each of the 93 health institutions, for a total of 5022 months of observations, to calculate the DHIS2 reporting rate summary for the service delivery/Malaria/NTD/NCD data factor. Valid reports were obtained for 4980 (99.2%) months of observation, with an average monthly reporting rate (completion rate) for facilities at 94.8%. The control health facilities reported an average monthly rate of 95.7%, which was slightly higher than the intervention health facilities' rate of 93.1%.
However, in 2021, intervention facilities reported a lower average rate of 89.5%. In terms of timely reporting, the average monthly reporting rate across all facilities was 51.5%. The average monthly reporting rate on time among control health institutions was 50.9%, compared to 52.7% for intervention health facilities. In 2022, the average on‐time reporting percentage was slightly lower at 38.1%. While intervention facilities showed higher reporting accuracy and quality of care, timely reporting remains a challenge, potentially affecting the real‐time monitoring of hypertension care delivery.
3.6. Difference‐in‐Difference Regression Analysis
Using a DID regression analysis, the NORAD‐WHO intervention increased hypertension screening in all age groups and this was found to be statistically significant. Accordingly, after adjusting for the effect of other covariates, the NORAD‐WHO intervention increased the number of hypertension screenings among all ages by 425 clients per month on average (95% CI 131, 719, p = 0.04).
Even though it was not statistically significant, the NORAD‐WHO intervention increased the number of newly diagnosed hypertensive patients, hypertensive patients on treatment, and patients with controlled blood pressure on average per month in intervention facilities compared to their counterpart control facilities. However, the observed increase in these indicators suggests potential benefits of enhanced screening protocols (Table 7).
Table 7.
Difference‐in‐difference output for the screening, diagnosis, and treatment of hypertension services in selected public health facilities (n = 93 health facilities).
| ATET (intervention vs. control) | Coefficient | Robust std. error | t | p > t | 95% CI | Parallel‐trends test** |
|---|---|---|---|---|---|---|
| Hypertension screening among all ages | 425.1 | 23.12 | 18.39 | 0.035* | 131.36, 718.83 | 0.38*** |
| Newly diagnosed hypertensive patients | 3.12 | 0.28 | 11.1 | 0.057 | −0.46, 6.71 | 0.46*** |
| Hypertensive patients on treatment | 82 | 9.84 | 8.34 | 0.076 | −42.97, 207.1 | 0.84*** |
| Controlled blood pressure | 55.22 | 18.64 | 2.96 | 0.21 | −181.57, 292 | 0.4*** |
Note: ATET estimate adjusted for covariates (facility type, availability of functional blood pressure apparatus and stethoscope, and availability of core antihypertensive and cardiovascular medications), group effects, and time effects.
Abbreviations: ATET, average treatment effect for treated; CI, confidence interval.
statistically significant at the 0.05 level of significance.
Parallel‐trends test assumption is satisfied when the linear trends are parallel and p > 0.05
Parallel‐trends test assumption satisfied.
As depicted in Figure 1, both the graphical assessment of parallel trends and formal statistical tests confirmed that the monthly average number of patients screened (A), diagnosed (B), treated (C), and with controlled blood pressure (D) in the intervention and control health facilities supported the parallel trend assumption for the DID regression analysis.
4. Discussions
This study provides critical insights into the impact of the NORAD‐WHO intervention on hypertension care in Ethiopia, addressing gaps in availability, utilization, and quality of services in LMICs. Even though there are more than 1.28 billion hypertensive people in the world, two‐thirds of whom live in LMICs [20], and nearly 2 out of every 10 adults over the age of 18 have hypertension in Ethiopia [21], hypertension remains a neglected public health issue. While research is underway in many regions of the world, Ethiopia has produced relatively little specifically linked to the topic. Given the unique nature of this study and its restricted staff and logistical support, more scientific research is needed to confirm the efficacy of these intervention centers. In this way, the current study will help researchers make plans for their next investigations.
This multicenter quasi‐experimental study compared the availability, utilization, and quality of hypertension care delivery, as well as the availability of medical supplies and pharmaceuticals, between NORAD‐WHO project intervention implementers and non‐implementing neighboring health facilities. It was carried out in 93 public health facilities spread across six regions and one city administration. The proportion of health facilities providing the services had increased from 64.5% to 93.6% in intervention facilities and from 51 (82.3%) to 56 (90.3%) in control facilities.
This finding is consistent with the study conducted in the Mukono and Buikwe Districts of Uganda; out of the 126 health facilities, 92.9% provide diagnosis and treatment for patients with hypertension [22]. However, this finding is significantly higher than that of another Ugandan study, where 66 (86%) of 77 health facilities offered comprehensive hypertension diagnosis services [23]. Similarly, a study conducted in Vietnam found that hypertension management services were available in 62% of the community health stations [24]. Likewise, this finding is higher than a study conducted in Osun State, South‐West Nigeria, where 43 of 66 health facilities (65.15%) provide hypertension prevention, diagnostic, and management services [25].
This disparity in the implementation of the hypertension service provision could be attributed to changes in study periods, with ours being the most recent, as countries prioritize NCD prevention and control, including hypertension. Additionally, this variation could be due to the differences in the nature of the facilities, where in our study we have both primary hospitals and health centers, whereas the above studies only used the health centers. Importantly, this finding has policy, scientific, and clinical implications, emphasizing the importance of improving and decentralizing hypertension care services into the PHCUs.
In the present study, we have found that the availability of national or WHO treatment guidelines for hypertension significantly increased between 2019 and 2023. The availability of hypertension treatment guidelines in intervention facilities (96.7%) was significantly higher than reported in Uganda (46%) [22] and Nigeria (19.3%) [26], underscoring the intervention's role in improving adherence to standards. This discrepancy could be attributed to differences in the attention paid to the implementation of such standards in health facilities. The availability of supportive guidelines may have an impact on improving healthcare providers' knowledge of hypertension, which they can then apply in their daily service provision.
This finding has implications because the availability of necessary standards for the diagnosis and treatment of hypertension in health facilities has the potential to improve healthcare practitioners' service delivery. In the present study, we found that the number of health facilities having a trained staff capable of providing comprehensive hypertension care services increased from 18 (58.1%) to 31 (100%) in the intervention facilities and from 30 (48.4%) to 39 (62.9%) in the control facilities.
In contradiction, this finding is higher than the study conducted in the primary health centers in Nigeria, which found that staff training in hypertension found that 71 (22.3%) of the 305 primary health centers [26]. Training on hypertension diagnosis had not been given to 83% (64 of 77) of health facilities in the Ugandan study [23]. This could imply that the more health professionals get capacity‐building training, the greater the service availability in healthcare facilities and this could potentially affect the implementation of national and international prevention and control goals.
In the present study, in the first 6 months of the year 2023, the monthly average number of individuals screened for hypertension was 682 among intervention facilities and 278 among control facilities. Similarly, in our study, the average number of newly diagnosed hypertensive patients was 6 in the intervention facilities and 4 in the control facilities. This finding was consistent with a study conducted in Uganda, which found that the average number of people screened for hypertension in 1 month was 660, with an average monthly number of newly diagnosed hypertensive patients of 7 [22].
In the present study, we found that there were, on average, eight functional blood pressure devices per month in the intervention and control facilities. Similarly, there were on average eight functional stethoscopes in the intervention facilities and seven in the control facilities in the first 6 months of 2023. A study conducted in the Wakiso District of Uganda found that 53 of 77 (69%) of the health facilities have functional blood pressure measuring devices [22]. A study conducted in the primary health centers in Nigeria found that a sizeable percentage of these instruments (23.5%) were not functional in the rural health facilities [26].
BP apparatus availability was 284 (93.1%) out of the 305 primary healthcare facilities and functionality was 243 (85.6%) of the 284 health facilities. Stethoscope availability and functionality were found to be 285 (93.4%) and 251 (88.1%) [22]. In the study conducted in the Mukono and Buikwe Districts of Uganda, of the 126 health facilities, the mean number of stethoscopes per level of health facility was 1 [22]. Discrepancies in medication availability likely reflect differences in study timelines and measurement approaches, with this study assessing longitudinal trends rather than a single point in time.
In the present study, in the first 6 months of 2023, we found that CCBs were available in 163 (89.6%) of the 186 months of follow‐up and 305 (87.6%) of the 372 months of follow‐up in control facilities. A study conducted in primary health centers in Nigeria [26] found that nifedipine and amlodipine were present in 40.8% and 39.7% of the primary health centers, respectively. In Uganda, CCBs were available in 48.4% of the facilities [23]. In our study, thiazide diuretics were available in 142 (85%) months in the intervention facilities and 233 (65.8%) months in the control facilities. However, thiazide diuretics were available in 42.9% of the facilities. ACE inhibitors were available in 136 (78.2%) months in the intervention facilities and 238 (68.4%) months in the control facilities. However, this was found to be higher than the study conducted in Nigeria, where ACE inhibitors were available in 22.2% of the facilities [26].
The disparity in the availability of various antihypertensive drugs seen in this study could be attributed to discrepancies in measurement scales. Our study examined the availability of such drugs in each month over the last 4 years and 6 months; however, the other studies looked at a single point in time, which does not represent the overall availability of these medications in healthcare facilities. The second reason could be a shift in time; as government, partner, and community concerns grow, these core antihypertensive drugs will become more widely available. This finding has implications: to ensure long‐term improvements in hypertension care, governments and partners should prioritize consistent drug supply chains, expand staff training programs, and integrate monitoring systems to track medication availability and service quality.
4.1. Strengths and Limitations
This is Ethiopia's first nationwide study of 93 public health facilities, including urban and rural health facilities, health centers, primary hospitals, and facilities with and without physicians. To ensure that the findings were valid and representative, we collected data from a variety of health institutions using the WHO's standard Service Availability and Readiness Assessment method (SARA). While the study provides robust evidence, missing data in some regions may limit the generalizability of findings, particularly for rural facilities in conflict‐affected areas.
5. Conclusions
In the present study, we have found that the screening, early detection, and treatment services for hypertension had significantly improved for intervention facilities compared to controls between 2019 and 2023. The NORAD‐WHO intervention significantly enhanced hypertension care delivery in Ethiopia, improving screening, diagnosis, and treatment across intervention facilities compared to controls. To sustain these improvements, policymakers should prioritize consistent availability of essential medications, expand staff training programs, and implement robust data management systems to inform regional planning. Addressing data quality management challenges is crucial to ensure reliable evidence for scaling up hypertension care interventions and addressing regional disparities.
Author Contributions
Zenawi Hagos Gufue: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing – original draft, writing – review and editing. Yimer Seid Yimer: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing – original draft, writing – review and editing. Meaza Gezu Shentema: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing – original draft, writing – review and editing. Awgichew Kifle Zemelak: data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing – original draft, writing – review and editing. Zeytu Gashaw Asfaw: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing – original draft, writing – review and editing. Sefonias Getachew: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, supervision, validation, visualization, writing – review and editing. Kalkidan Solomon: conceptualization, data curation, formal analysis, investigation, project administration, resources, supervision, validation, writing – review and editing. Mulugeta Tamire: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing – review and editing. Asmamaw Bezabeh Workneh: conceptualization, data curation, funding acquisition, investigation, methodology, project administration, resources, validation, writing – review and editing. Girma Taye Aweke: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing – original draft, writing – review and editing. All authors have read and approved the final version of the manuscript.
Ethics Statement
Ethical approval was obtained from the Institutional Review Board of the College of Health Sciences, Addis Ababa University (Ref No. 063/23/SPH). The Ministry of Health provided a letter of support to all regions and city administrations to help with data collection. Simultaneously, all regions issued a letter of support to the chosen health facilities and shared all relevant data sources with the data collectors during the collection period. The data collected from registration logbooks, chronic follow‐up clinics, and the pharmacy department were strictly confidential.
Consent
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
The lead author Girma Taye Aweke affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Supporting information
Supplementary File 1: The RECORD statement – checklist of items, extended from the STROBE statement that should be reported in observational studies using routinely collected health data.
Supplementary File 2: Data extraction checklist.
Acknowledgments
The authors wish to express their heartfelt gratitude to all study data collectors and regional supervisors for their invaluable contributions to the success of this study. Their dedication, attention to detail, and tireless efforts have helped ensure the collection of high‐quality data, which serves as the foundation for our research findings. The authors recognize and appreciate each individual's dedication and professionalism, without which this study would not have been possible. The World Health Organization Ethiopia country office funded this study to evaluate the NORAD‐WHO NCD initiative in Ethiopia's primary healthcare facilities. The funder had no role in the study design; collection, analysis, and interpretation of data; writing of the report; and the decision to submit the report for publication. Patients and/or the public were not involved in the design, conduct, reporting, or dissemination plans of this study.
Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article and/or its supporting materials. Girma Taye Aweke had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary File 1: The RECORD statement – checklist of items, extended from the STROBE statement that should be reported in observational studies using routinely collected health data.
Supplementary File 2: Data extraction checklist.
Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article and/or its supporting materials. Girma Taye Aweke had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.