How Africa e-delivers last-mile care for hypertension
Four African countries have deployed digitisation to offer screening, early detection, management and follow-up services for hypertension at primary care centres.
Hypertension continues to live up to its ‘silent killer’ reputation, accounting for approximately 8.5 million deaths globally. The diagnosis of hypertension often comes with debilitating health and economic consequences not only for the individual and household, but also health systems and countries, typically due to late diagnosis when complications have set in.
While hypertension is largely preventable through cost-effective lifestyle measures, close to a third (27%) of the African population is estimated to be living with the condition. The good news is that, when diagnosed early and managed, people with hypertension can lead a long and productive life. The bad news is that over half of persons with hypertension in sub-Saharan Africa (SSA) are unaware they have the condition, and therefore highly predisposed to developing complications and dying prematurely.
Among people diagnosed with hypertension, there is limited access to care and poor blood pressure control—only about a third are on treatment and one in 10 have blood pressure under control in SSA. This is compounded by the fact that, traditionally, hypertension has been diagnosed and managed at secondary and tertiary facilities, which are often few, far, and congested. Inadequate information systems and paucity of data are also major hindrances to hypertension programming in the region. These challenges are not surprising, given the disproportionately low attention—strategic, planning and financing—given to hypertension and other non-communicable diseases (NCDs).
Care powered by data
As the countdown to the attainment of Sustainable Development Goals (SDG) 3.4—reducing premature NCD deaths by one-third by 2030—gains momentum, we have an opportunity to address the largest contributor to these deaths: hypertension. It is with this in mind that Medtronic LABS, in partnership with ministries of health, faith-based health networks, NGOs and private sector, has deployed an end-to-end digital health-enabled programme for screening, early detection, management and follow-up of hypertension at primary care level in four African countries.
The programme includes awareness creation, screening and referral for hypertension, diabetes and overweight/obesity at household and community level by trained and kitted community health workers (CHWs). The CHWs feed the readings for blood pressure (BP), blood sugar, weight, and height, besides basic socio-demographics into an electronic platform (SPICE) with in-built decision support tools. The digital platform gives a notification when the readings are outside the normal range and facilitate referral and linkage to care.
At the health facility, equipped with tablets loaded with SPICE, health workers can keep tabs on , community-based screening activities and referred patients. The platform has in-built decision support tools for the health worker, as well, to aid cardiovascular risk calculation and personalised care plans, among other clinical care parameters. The facility module has a laboratory and pharmacy sub-module. Patients are linked back to community-based follow-up, where they get routine BP, blood glucose and basic symptom checks, as per their personalised care plans.
The programme includes tele-counselling for adherence support and targeted patient education, as well as psychosocial patient support groups. SPICE has in-built dashboards for real-time tracking of both individual and aggregate patient data. It also generates customised Ministry of Health (MOH) reports, which are fed into the respective countries’ DHIS2 platforms, substantially saving on the time health workers spend in writing down this information.
The SPICE-enabled hypertension care model
Programme implementation is embedded within the mainstream health system infrastructure, leveraging on ministries of health for policy direction and clinical guidelines; sub-national teams and other partners such as faith-based health networks are roped in for capacity building, oversight, quality assurance and front-line implementation. Less than five years since its launch in Africa, the programme has supported over 298,000 screenings and the enrolment of over 104,000 hypertensive patients into long-term, digital- enabled longitudinal care in Ghana, Kenya, Tanzania and Sierra Leone, and will soon launch in Rwanda.
Patience Mbekelu, a 50-year-old woman with hypertension and diabetes, is a beneficiary of the programme since late 2021. She lives in Mtwapa, in the Kenyan coastal region. Mbekelu is among the 33,093 hypertensive patients who underwent a follow-up BP check during the three months preceding November 2022 through the program, and 59% of them, including Mbekelu, had BP within control range. She says she is able to take care of herself better now that the services are available at a primary care facility close to her, reducing her cost of travel. Before a hypertension clinic was established in Mtwapa, she had to travel over 60 kilometres to the Kilifi County Referral Hospital for her routine follow-up, which was not easy for her. “I also appreciate the calls I get from the telecounsellors to remind me when I miss a clinic appointment or a BP assessment,” she told us. Mbekelu and the other programme beneficiaries also receive ‘health digest’ text messages on healthy lifestyle. The Mtwapa Health Center is among the 192 health facilities participating in the programme across the region. Half of these facilities are primary care sites, which have been activated to provide hypertension services to people living nearby. Besides BP monitoring, the programme features other innovative initiatives such as ‘patient open days’ at community or facility locations for group-based education and monitoring, as well as decentralisation of BP monitoring services to community-based ‘feeder-sites’.
Mbekelu 's clinician, Daisy Juma, is part of a multi-disciplinary team of over 3,000 health workers, 1,300 CHWs and 400 peer educators trained by the programme. Juma has been using SPICE to manage and monitor her patients, and she now finds it easier to access data for individual patients as well as aggregate facility. “Having real-time visibility of patient BP trends or worrying symptoms even when monitored remotely enables us to take prompt action to prevent complications,” she says.
The potential demonstrated by this programme is being leveraged by the Kenya Ministry of Health, in partnership with the World Diabetes Foundation, to create an additional 360 primary care facilities, targeting to screen at least 500,000 and enrol over 300,000 people with hypertension and/or diabetes for long-term care. Scale-up of such innovative, digital health-enabled primary care models is a feasible and sustainable way to turn the tide of the hypertension crisis in Africa.
We acknowledge GIZ, Novo Nordisk, Sanofi Global Health, PATH, Novartis, MOH Kenya and Christian Health Associations of Ghana, Sierra Leone and Tanzania for their financial and technical support towards the success of this programme