Integration of a hypertension treatment programme into Nigeria’s primary healthcare system: report from a stakeholders and policymakers’ workshop

Nigeria, the most populous country in Africa with a population exceeding 200 million, has an estimated hypertension prevalence of 38%, which is a major contributor to the burden of hypertension-related disease in Africa.1,2 Compounding this rising burden are low rates of awareness, treatment, and control of hypertension, attributed to insufficient health system readiness and response to meet the large and rising need for hypertensive services.3,4 The World Health Organization HEARTS technical package, comprising standardized treatment protocols, healthy-lifestyle counselling, access to essential medication, risk-based cardiovascular disease management, team-based care, and systems for monitoring, has emerged as a promising approach for systematically integrating multi-level, evidence-based strategies into primary healthcare, with hypertension as a clinical entry point.5 In collaboration with the University of Abuja (Nigeria), Washington University in St. Louis (USA), and Northwestern University (USA), the Hypertension Treatment in Nigeria (HTN) Programme was launched in 2020 to improve the cascade of hypertension care across 60 primary healthcare centres in the Federal Capital Territory, Nigeria.6 The programme has adapted, implemented, and evaluated HEARTS through a hybrid type II effectiveness implementation, interrupted time series design (NCT04158154). These adaptations included (i) simplified treatment protocol (national policy level), (ii) prioritization of fixed-dose combination therapy (health system level), (iii) patient registration and empanelment (health system level), (iv) team-based care led by trained and supported community health extension workers (health worker level), (v) home blood pressure monitoring and health coaching (patient level), (vi) free or reduced cost medications through drug revolving fund implementation (patient level), and (vii) public health messaging and community mobilization (community level).6–8 Since the inception of the HTN Programme, 21 922 patients have been enrolled, with 51.3% identified as newly diagnosed with hypertension. Hypertension control rates, defined as blood pressure < 140/<90 mm Hg, increased from 32.5% to 55.9%. Corresponding implementation outcome analyses show high levels of reach, adoption, implementation, and maintenance of the programme. The next logical step of the HTN Programme is to scale up hypertensive services nationally. The effective integration of research evidence into policy and the proactive engagement and communication of research findings with key stakeholders lie at the core of equity-centred research. Although stakeholder engagement throughout the research process has been demonstrated to increase the likelihood of adoption and sustained implementation of evidence-based strategies for hypertension control, there remains a limited understanding of how to engage stakeholders and leverage their unique contributions in research projects.9 In the HTN Programme, the research team has sought to bridge this gap by engaging diverse stakeholders throughout the research process to plan, share results, and discuss emerging priorities and future directions. To this end, the HTN Programme team convened its latest stakeholder meeting on Wednesday, 24 April 2024, in the Federal Capital Territory, Nigeria with the following objectives: (i) to assess the current evidence on the reach, effectiveness, adoption, implementation, and maintenance of the HTN Programme; (ii) to leverage expertise from different levels of governmental agencies or institutes to identify opportunities and challenges and widespread translation of evidence; and (iii) to identify collaboration opportunities among stakeholder groups to support scale and sustainment beyond the end of the study. Forty-five participants attended, including staff from the Non-Communicable Disease Division and Department of Public Health of the Federal Ministry of Health, Department of Public Health and FCT Primary Healthcare Board, directors of primary health care in local government councils in the FCT, pharmacists, health educators, and mobilizers working in the local government council in the FCT, staff of the World Health Organization, Resolve to Save Lives and Healthy Heart Africa. The leadership of the Nigerian Hypertension Society including members of the board of trustees, members of the advisory board of HTN Study Team, and representatives of patient advocacy group, the leadership of the University of Abuja and the University of Abuja Teaching Hospital, and the academia were also present. A comprehensive participant selection process was coordinated by the research team for this meeting, aiming to ensure balanced organizational representation and diverse expert opinions. A group photograph of participants at the meeting including the vice chancellor of the University of Abuja is seen in Figure 1. Photograph displaying the participants at the joint investigators and stakeholders’ meeting at the Hypertension Treatment in Nigeria Programme Stakeholders from the Nigerian Hypertension Society emphasized the importance of harmonizing and developing a unified guideline for HTN. Furthermore, stakeholders agreed that ensuring a continuous supply of affordable quality hypertension medication was crucial for long-term, programmatic success. They also agreed with the process of adaptation, implementation, and evaluation of a drug-revolving fund utilized by the study team to maximize the accessibility of blood pressure-lowering drugs within the primary healthcare centres. There were also discussions on the importance of incorporating hypertension medications into Nigeria’s essential medication list to facilitate coverage by health insurance scheme. The success recorded in incorporating anti-hypertensive medications in the Nigerian Hypertension Treatment Protocol through the collaborative effort of the Non-communicable Disease Division of the Federal Ministry of Health, Resolve to Save Lives, and University through scientific presentations strong advocacy efforts was commended. There was a call to review in-service training curricula for community health extension workers to ensure hypertension management becomes integrated into the overall syllabus of training of this cadre of healthcare workers. There were also discussions on harmonizing all data from hypertension control programmes in the country into a national electronic database using the district health information system. Finally, the need for expanded community engagement and awareness creation was discussed. All participants agreed that the HTN Programme has made significant strides in advancing the science of implementation of HEARTS into primary healthcare in the Federal Capital Territory of Nigeria. They concluded that through stakeholder engagement and subsequent policymaking, the programme can be a template for integrating hypertensive services into primary care at the national. Hypertension Treatment in Nigeria investigators and staff: Lisa Hirschhorn, Nana Ripiye, Ikechukwu Orji, Gabriel Shedul, Tunde Ojo, Jiancheng Ye, Boni Ale, Grace Shedul, Namratha Kandula, Eugenia Ugwuneji, Abigail Baldridge, Nonye Egenti, Rosemary Okoli, Bolanle Banigbe, Regina Asuku, Elizabeth Ngadda, Joel Abu, Alice Osuji, Blessing Akor, Charity Akor, Christine Archibong, Abuba-kar Haruna, Confidence Joseph-Alo, Emmanuel Odo, Douglas Okoye, Grace Afolabi, Emmanuel Okpetu, Dorothy Ihegazie, Christian Ukeh, Vivian Chukwuma, Olutobi A. Sanuade, Nicholas Baamlong, Sani Mohammed, Deborah Joshua, Saleh Ashafa, Hope Omeiza, Mercy Ikechukwu-Orji. Participating organizations: University of Abuja; University of Abuja Teaching Hospital; Washington University in Saint Louis; Northwestern University; Federal Ministry of Health of Nigeria; World Health Organization, Nigeria Office; Federal Capital Territory Public Health Department; Federal Capital Territory Primary Health Care Board; Resolve to Save Lives; Nigerian Hypertension Society; Healthy Heart Africa; mDoc Healthcare Ltd.