Use of Primary Healthcare Facilities for Care and Support of Chronic Diseases: Hypertension

Abstract

Hospitalisation of chronic diseases can be costly and time-consuming to patients with chronic diseases, and success of management of chronic diseases is in the primary care. This chapter gives a detailed description of primary health and its role in the management of chronic diseases. Hypertension as a chronic disease of interest and its management in the primary healthcare (PHC) context are also to be discussed in detail. However, to give this chapter clarity, a brief description of the country Lesotho will be given. The summary of the country will highlight major barriers to health care which mainly include poverty, difficult topography with no or poor infrastructure which hinder access to primary health care. Situational analysis is made with regard to current practice. The potential role of a pharmacist in the care and treatment of hypertension is explored. Best practices, need for policy change, guidelines and implementation plans will be highlighted. The aim of the chapter is to evaluate how chronic diseases are managed at the primary health care. The objectives include: a) to explore primary health care concept, b) to critically evaluate PHC concept in an African country and c) to describe human resource needs to meet the demands of PHC chronic diseases management.

1. Introduction

The Lesotho Kingdom is a relatively small country, 30,360 km² divided into 10 administrative districts and further divided into four ecological zones, namely the lowlands, foothills and highlands (mountains) and the Senqu valley [1]. The mountainous terrain makes ground travel very difficult in Lesotho [2]. The mountainous topography and harsh winters make it difficult to access essential services, including healthcare services [1]. The Republic of South Africa surrounds Lesotho, with a population of slightly more than 2 million [1]. About 99% of Lesotho people are ethnic Basotho, with Christianity being the majority religion. The national languages are Sesotho and English [2]. Altitudes in Lesotho range from 4500 to over 13,000 feet, and 33% of Lesotho population resides in the urban areas leaving the majority of the population living in the mountain areas. High mountains cover about two-thirds of the country, and snow is expected in the winter months [3].

Lesotho, classified as a lower-middle-income country with a per capita income of US$1879, ranks 161 out of 187 countries on the UN Human Development ranking [4]. National poverty figures indicate that 57.1% of the population lives below the national poverty line [4]. Poverty is particularly acute in the mountainous areas, which are hard to reach [5]. Besides, Lesotho’s economy is dependent on clothing and textiles; diamond extraction; exports of water to South Africa and workers’ remittances from the Southern African Customs Union (SACU) [4]. The agricultural sector, which accounts for only 8.6% of Gross Domestic Product (GDP), is the primary source of income for the majority of the rural population [4].

The World Bank and UNICEF report indicates that the main priority for the Ministry of Health (MoH) should be to strengthen its control systems both for compliance which now appear extremely weak as well as performance at all levels (centre, district, facility level) [6]. The health system looks very fragmented, with several pools of resources from donors and government and different service providers operating according to different priorities and operating mechanisms and without any accountability for results.

The health outcomes for major indicators remain poor despite the increase in funding by the government [6]. Considering the fact that HIV prevalence and incidence are slowly improving, TB incidence, maternal and infant mortality rates remain among the highest in the world [6]. The Government of Lesotho (GoL) should strive to meet the objective of universal health coverage, the quality and cost-effectiveness of health care and increase access to underserved populations within a very tight budget [6]. Therefore, more quantifiable efforts have to be taken towards getting outputs worth the investment made on health system.

To clarify this further, the government of Lesotho has incurred increased expenditure in the District Health Management Teams (DHMTs) (135%) and Christian Health Association of Lesotho (CHAL) (121%). Another increased expenditure was seen in laboratories (126%), planning (163%) and pharmaceuticals (162%) [6]. Perhaps, the increase in DHMT expenditure may be understandable as it is the main implementer of decentralisation of health service delivery at the primary healthcare level [6]. However, looking at the topography of the country, it is believed that the community councils may play a similar role with better cost-effective health outcomes.

2. The concept of primary health care

In Lesotho, PHC is provided at health centres (HCs) and health posts and at community level [2]. Community health workers, also known as village health workers (VHWs), are patients’ first formal contacts with the health system. The VHWs are trained community members who help patients in the community and form a link between communities and health centres [7]. Implementers at the health centres can, therefore, play an important role in decreasing the need for higher-level referral by providing integrated service delivery [8].

Lesotho adopted the Alma-Ata Declaration in 1979 [9]. The Lesotho National Health Policy, which has been used in draft form since 2004 [9], is largely based on the Alma-Ata Declaration on PHC and involves the establishment of 18 health service areas. The District Health Management Teams (DHMTs) are responsible for PHC activities in health centres at a district level. The staffing of health centres (HCs) is determined by whether the facility is rural and small in size or urban and larger in size. Rural HCs are manned by registered nurses while urban ones have registered nurses, doctors, pharmacists and laboratory technologists [9].

Primary health care (PHC) was conceptualised and agreed to be a global solution to the problem of providing comprehensive health services to all at the Alma-Ata Conference in 1978. The conference defined PHC as,

‘essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community, through their full participation and a cost that the community and country can afford to maintain, at every stage of their development in the spirit of self-reliance and self-determination’ [10].

Sadly, the implementation of comprehensive service delivery as determined by the Alma-Ata Declaration failed to be consistent and was fragmented based on financial, disease-specific and strategic reasons; therefore service provision of varying degree is continuously offered. However, the integration of essential services and strengthening of health services comprise quantifiable comprehensive service delivery [11, 12].

The low-and-middle income countries, including Lesotho, have selected and serious health problems that are given special attention, and this results in fragmented services. An overwhelming disease burden, donor-driven care and unclear frameworks, guidelines or indicators of PHC are responsible for the prevailing fragmentation of care [11]. The issues of a holistically, patient-centred approach can be met by adopting an integrated service delivery models. The integration of PHC services approach not only embraces the ‘best practice’ model, and can prevent duplication of services, reduce the risk of adverse events and consequently improve quality of care [11, 13].

The sustainability of health care can be maintained by paying attention to all diseases, not only to prioritised diseases as this creates gaps instead of strengthening the health system [11]. Consequently, the prevalence of preventable illnesses has increased. Conditions, such as hypertension and diabetes, are increasing yearly despite highly specialised care [14]. This results in increasing prevalence of these preventable conditions, patients who receive fragmented service delivery have to visit health centres to receive different specialised services on different days for different, but related, health needs [15]. The consequences of separate, specialised services undermine holistic individualised patient care, patients’ adherence to medication, multiple clinic visits, each time enduring long waiting periods, with endless referrals between departments, resulting in high patient ‘no-show rates’ for appointments [11, 16].

The National Health Sector Strategic Plan 2012–2017 and the Lesotho PHC Revitalisation Plan 2011–2017 show how Lesotho recommitted itself to the original Alma-Ata Declaration for all health centres, including the health centres in Maseru district [7]. Also the Ministry of Health (MoH) undertook several health reforms [7, 8].

It is, however, indicated that lack of formal framework with documented strategies leads to haphazard implementation of integrated primary health care (IPHC), and the Lesotho national policy is also wanting in this regard [8, 17]. It is therefore indicated that when the registered nurses implement IPHC, they based themselves on their own understanding. According to Posholi, to date, PHC has had very few comprehensive implementation frameworks or guidelines [17]. Again, Valentijn et al. stipulate a serious need for standardised, tabulated, systematic procedures for implementation of IPHC [12]. In the absence of standardised protocols across settings, PHC implementation remains subjective and, sometimes, misguided [17, 18]. Even the WHO has cautioned that the absence of standard guidelines for implementation has the potential to derail the initial vision of PHC [19].

It was indicated that the MoH depends on registered nurses to implement IPHC. They are the key personnel who attend to the patients visiting health centres, then referred to a higher level of care, if needed, based on the patient’s diagnosis [20]. The registered nurses employed at the health centres report to the registered nurse in charge of the health centre, who in turn report to the relevant DHMT [21].

As initially planned, PHC brings health promotion, disease prevention, cure and care together in a safe, effective and socially acceptable manner to the community [22]. The report by Stender et al. further discusses the skills that are acquired and the training that healthcare workers at the PHC level receive [22]. These included history taking, performing a physical examination and making a nursing diagnosis during a client consultation, problem-solving and decision-making skills especially in the absence of a doctor and completing patient records as well as an appreciating the importance of recordkeeping. Stender et al. point out one of the key elements of PHC which involves bringing health care closer to where people live by conducting home visits and facilitate community involvement in health care through community outreach [22].

3. Healthcare human resources

Health worker density is the most widely used indicator to determine available human resources [23]. The WHO has set a density indicator of 2.23 healthcare professionals per 1000 population as the minimum threshold for access to public healthcare services [24]. Within that benchmark, significant variance exists between regions regarding the particular skills-mix of doctors, nurses and midwives. In the Africa continent, there are on average five nurses/midwives per doctor [25]. Zimbabwe’s health worker density at 1.45 per 1000 of the population is higher than those of Sierra Leone and South Sudan but is still less than the WHO’s density benchmark [23]. In Botswana, according to Nkomazana et al., the health worker density is 3.4 doctors and 28.4 nurses per 10,000 of the population [25]. In Lesotho, however, health workforce is challenged to meet the needs of its population. The nursing and midwifery workforce is 6.0 per 10,000 compared with neighbouring South Africa’s 41 per 10,000 and 11 per 10,000 for the Africa region [24].

The Lesotho government staff establishment has not been reviewed; therefore it does not take care of health cadres that are needed resulting from the use of modern health technologies, for example, equipment, devices and protocols [26]. Furthermore, there is an acute shortage of expertise within the health sector with many posts on the establishment list of the MoH remaining unfilled. The overall establishment list of the MoH was at the beginning of the year 2015 was 4610. Over half (54%) of nurse and midwife posts remain vacant in rural areas [27]. At the end of the 2015 financial year, only 23% of all vacancies were filled. Several factors have been associated with this, such as local circumstances that negatively impacted on training, pay, infrastructure and working conditions [26]. However, the country could consider changing some of the posts to cover other cadres in order to add diversity to the nursing cadres and leave nursing within the mandatory scope of work that is done well.

4. Community pharmacy as primary healthcare facilities

Stimulating a professional relationship between a pharmacist and patient begins at the community level because patients must perceive pharmacists as necessary experts within the healthcare system [28]. The role of a pharmacist in dealing with minor health problems is well established, and pharmacists are also viewed as professionals who are an accessible source of information and advice [24]. This, therefore, implies that the community’s health is in the hands of the community pharmacists; hence their practice should be well regulated and monitored. Figure 1 depicts the scope of pharmacy in Lesotho in terms of regulation, education practice and research.

Figure 1.

The scope of pharmacy practice in Lesotho.

5. Disease burden

The country is faced with enormous health challenges; as nearly one-quarter of adults 15 − 49 years of age are living with HIV (22.9%) [29], and Lesotho is considered to have the world’s second highest tuberculosis incidence rate at 916 cases per 100,000 population [30, 31]. Lesotho as a country also has one of the highest maternal mortality ratios in the world at 490 per 100,000 live births, with a lifetime risk of maternal death at 1 in 64 [32]. According Lesotho Demographic and Health Survey (LDHS), there were 19% of women and 13% of men aged 15–49 who have hypertension [26]. One in five women and one in seven men with hypertension (5% of all women and 2% of all men age 15–49) have their hypertension controlled with medication [26].

6. Hypertension as a chronic disease

Worldwide, the leading risk factor associated with morbidity and mortality from non-communicable diseases (NCDs) and the highest cause of premature deaths is reported to be of those of hypertension [33]. The global prevalence of hypertension in adults aged 18 years and over was around 24.1% for men and 20.1% for women in 2015 [33]. Based on the statistics of hypertension reports for the past years, the WHO predicts that, by the year 2025, almost 75% of the world’s hypertension population will be found in developing countries [33]. However, the global action plan has a target of a 25% reduction of the global prevalence of hypertension [34].

Nonetheless, recent statistics on the prevalence of chronic diseases in Lesotho indicate that the presence of hypertension was reported to be at 41% in 2015 [35]. Inevitably, hypertension ranks among the top causes of morbidity and mortality and is the third-most common cause of hospital admissions in the country [2, 36].

An accurate measurement of blood pressure with a well-fitting calf remains an important part of diagnosis of primary hypertension [37]. In an adult, the normal blood pressure is said to be 120/80mmHg [38]. A definite diagnosis of hypertension is when their blood pressure reading is above 139/89 mmHg on three consecutive clinical visit within two days up to a maximum of 7 days in between [39, 40]. This definition is consistent with the one found in the Lesotho national guidelines on the management of diabetes and hypertension at PHC level. Regarding sign and symptoms of hypertension, the following are said to be associate and these are tiredness, headaches, confusion, vision changes, angina-like pain and the presence of blood in the urine, nosebleeds, irregular heartbeat as well as ear noise or buzzing sounds [41].

The WHO recommends that once a patient is diagnosed with hypertension, as based on the nation’s guidelines, both pharmacological and non-pharmacological management measures must be initiated immediately [34]. In Lesotho, the treatment of increased blood pressure is guided by the national guidelines on the management of diabetes and hypertension at primary care level [39]. With regard to pharmacological management, the guidelines advise that diuretics, beta-blockers, calcium antagonists, converting enzyme inhibitors and angiotensin II receptor blockers are suitable for initial and follow-up treatment, as monotherapy and in combination [39].

Further advice on the prescription of the drugs, dosages and expected intervals for medication taking is included. However, treatment differs according to the individual’s blood pressure and compliance to treatment at the time of check-up. Furthermore, the guidelines recommend psychosocial support in terms of the suggested lifestyle changes (exercise, reduced dietary salt intake, reduced alcohol and tobacco intake) [39]. Patients with uncontrolled blood pressure despite medication adherence and lifestyle changes are referred to the secondary level of care for further investigations and management [39].

The effectiveness of hypertension treatment and experiencing its benefits relies critically on strict compliance to treatment instructions [42]. Rao et al. mention compliance is to treatment as a primary determinant of the effectiveness of treatment, which intensifies optimum clinical benefit and promotes good health [43]. Additionally, it is a cost-saving measure for a larger society, because the incidence of complications is decreased leading to less need for additional medications [33].

Globally, in comparison with acute diseases, chronic diseases treatment compliance rates are typically low and continue dropping radically despite increased awareness of the effect of chronic conditions [44]. There is still a need for improvement even among populations with relatively high adherence rates. According to Ivarsson et al., good compliance is a requirement worldwide, as reported in a national population-based cohort study conducted in pulmonary arterial hypertension centres in Sweden [45].

Hacihasanoglu and Gozum report that in Turkey, 40% of hypertension patients did not take their medications as prescribed and 50% defaulted on their appointment dates [46]. In contrast, Mafutha and Wright argue that medication-taking behaviour is not affected by failure to comply with follow-up appointments to collect medications [47]. Their study at primary healthcare clinics in Tshwane, South Africa, reported that 81% of patients were compliant regarding medication-taking, yet 57% were non-adherent to follow-up appointments [47]. Perhaps appointment keeping should be viewed in a broader context as the patient may come to the PHC facility before or after the appointed date or pick medicines from other facilities.

Some of the factors that are associated with missed appointments include lack of hypertension knowledge, experience of medication side effects, forgetfulness, transportation challenges, a feeling that appointments are not helpful, lack of trust and health professionals’ communication behaviour during consultations [48, 49]. Consequently, a particular factor associated with non-compliance of an individual hypertensive patient should guide interventions that improve appointment keeping compliance [49, 50].

There are few studies that address the compliance of patients suffering from non-communicable diseases in Lesotho. Most of the published research works on hypertension compare the knowledge of patients regarding antihypertensive treatment with treatment outcomes. Khothatso, et al. conducted an observational, descriptive cross-sectional study at a district hospital in Lesotho, the main findings are that there is low level of knowledge regarding their treatment and its adherence among hypertensive patients [51].

The study of Mugomeri, et al. reported that inadequate knowledge about antihypertensive treatment is significantly associated with uncontrolled high blood pressure and the associated complications [52]. A study conducted at Domicilliary Health Clinic in Maseru, Lesotho, reports that the prevalence of chronic, uncontrolled high blood pressure remains high in patients on treatment and claims an important intervention in this population would involve identifying factors that can help improve compliance to the hypertension treatment [36]. A report of a selective literature review study in various countries indicates, furthermore, that it is desirable to carry out studies on the promotion of compliance in Germany and countries facing the same national challenge of conditions prevailing in the healthcare system [53].

In their study, Wells et al. found that hypertension appeared to be one of the highest risk factors of heart failure [54]. Hypertensive patients have a higher risk of having heart attack, heart failure, stroke, kidney disease than normotensive people [55]. Saseen mentions that hypertension complications include atherosclerotic vascular disease which can be coronary artery disease, carotid artery disease, peripheral arterial disease and abdominal aortic aneurysm [56]. Other complications include cardiovascular diseases (CVDs) such as heart failure, chronic kidney disease and retinopathy.

Beaglehole et al. stated the need to distinguish approach between the management of chronic diseases and acute illnesses; they further mentioned the importance of the organisational or structural interventions in managing chronic disease [57]. It was highlighted that the PHC needed to be strengthened in order to undertake opportunistic case finding, for assessment of risk factors, early detection of disease and identification of high risk status for chronic disease can be carefully undertaken [57]. The development of management plans must take into account patients’ needs and preferences as chronic patients are said to be their own primary carers [57]. According to Siantz et al., in order to minimise functional limitations and disability, effective management of chronic conditions requires behavioural and lifestyle adjustments [58]. Therefore, an appropriate theoretical framework fitting the health problem of interest to change behaviour needs to guide the planned organisational interventions [59].

Patient must take up an active role in knowing and managing their own health, by expressing their concerns, preferences and participating in medical decisions; this can be achieved through patient empowerment, patient involvement and shared decision-making [60]. It is believed that informed patients improve their decisions by collaborating with their healthcare providers [61]. This results in increased patient’s involvement leading to a positive effect on the health outcomes.

On the other hand, Maimela et al. mentioned that PHC professionals often lack the resources such as quality equipment’s and promotional materials which could be used to assist local community self-management support services such as education programmes [62]. More so, the lack of continuous availability of medicines has become another important barrier for chronic disease management (CDM) in practice, and this plays an essential part in the provision of health care for chronic conditions [63]. The study of Wagner et al. suggested the need to transform a health system from responding mainly when a person is sick which is being reactive, but, rather be proactive and focused on keeping a person as healthy as possible which eventually improves the health of people with chronic illnesses [64].

7. Interventions models

It is noteworthy that Nyangu and Nkosi mentioned that registered nurse midwives and nurse clinicians manage the majority of PHC facilities, and their professional titles did not affect service provision [65]. However, it was suggested that there is a need to provide more staffing to address staff shortages and reduce patients waiting times at facilities [65]. Ideally, Uys and Klopper recommended that at least one specialist nurse, five registered nurse midwives and four enrolled nurses were needed for the effective running of PHC settings [66]. Additionally, the finding of Rampamba et al. revealed that encouragingly, the pharmacist intervention highly satisfied patients in PHC facilities in South Africa, and this laid a strong foundation for improving collaboration in the future [67]. Consequently, the study recommended that this intervention model be further developed and tested, with a greater focus on lifestyle changes and clinical outcomes. Pharmacists can further improve future control of blood pressure (BP) by routinely investigating and reviewing patient diaries [67].

Similarly, in Ghana, pharmacy curriculum for training pharmacists includes health promotion and health education, making it possible to undertake health promotion and disease preventative activities [68]. However, the national policy on prevention and control of chronic NCDs acknowledges the role of primary community facilities with no mention of community pharmacies [69].

Additionally, Afia et al. state that due to the increasing level of hypertension in low-income countries, community pharmacies could participate more in hypertension management interventions [70]. Nevertheless, the requirements for meaningful participation should be considered and realised which include the relevant staffing compliment, health promotion skill, pharmacy setting and referral systems [70]. Moreover, this service requires the constant presence of a pharmacist, screening space with privacy for counselling, staff training and referral linkages with the nearest health centre/clinic/hospital for referrals [70].

Furthermore, Omboni evaluated blood pressure telemonitoring (BPT) programmes involving a pharmacist; it was stated that this may require investment in laboratory monitoring and technologies [71]. Again, larger use of medications and more contacts with patients than standard care occur, there was a significantly improved BP control at relatively low cost or with an only minimal increase in healthcare costs compared with usual care. This would consequently lead to the reduced cost for future cardiovascular events. Interestingly, the economic analyses suggested that pharmacist case management provided the clinical gains as the current evidence to high-risk patients with stroke, evaluating the longer-term impact and cost-effectiveness of BPT with suggested by [72]. More so, the future analysis must consider cost savings from a reduction in cardiac events and long-term complications, as well as indirect or intangible costs such as travel time to clinic or time missed from work that would be relevant to an economic analysis from the societal perspective, particularly over several years [71].

8. Clinical management pathways

It is noted that the investment in predisposing factors awareness and health promotion with full participation of patients holds manifestation of the disease. Similarly, the key elements of management of chronic disease such as hypertension are in maintaining normal blood pressure, which leads to prevention of progression of disease and consequently its complications. Therefore, service provision takes into consideration prevention of disease, treatment of the disease, compliance to treatment, periodic reviews and close disease outcome monitoring. Is it possible to cover all this in the primary health care that has competing interest such as those imposed by communicable and acute illnesses? Is primary health care not burdened with mother and child health services, such as antenatal clinics and post-natal service?

Eventually, what remains unclear is, are the general nursing skills sufficient to carry the disease burden to desired treatment outcomes, for all the diseases in Lesotho? Is it time to look at how other countries manage hypertension using other professionals whose aim is to achieve desired treatment outcome? Is a pharmacist viewed in the context of medicines chain supply and dispensing or his/her clinical role in the management of diseases recognised? Is the pharmacist in a good position to play a role in the management of chronic diseases either in community pharmacy or primary healthcare setting? Is the pharmacist exposed to clinical pharmacy throughout the training, covering clinical management of diseases and pharmacy practice clarifying the role of a pharmacist in disease management, not only covering drug supply chain but also covers responding to symptoms in the pharmacy, pharmacoepidemiology, pharmacovigilance, pharmacoeconomics and drug utilisation reviews? Will these in due course benefit treatment outcomes of hypertension, improve treatment adherence, manage medication adverse drug reaction and based on treatment outcome in order to select the best treatment for the patient and carry out appropriate referral where needed?

Accordingly, study of Hallit et al. clarified that the PHC strategy of the Ministry of Public Health (MOPH) includes several programmes: communicable diseases, immunisation, mother and child health, nutrition, environmental health, non-communicable diseases, health awareness and essential medication [73]. Based on the above scenarios, in order to prevent disease progression, hospitalisation and poor prognosis of patients with hypertension, the following are proposed:

1. Retail pharmacists can be viewed as primary healthcare facilities, as patients who do not want long queues in the public sector sort services for their ill health. Currently, services include management of minor illnesses through over-the-counter (OTC) medicines and referrals where necessary. Also chronic diseases screening, prescription refills, monitoring and follow-up. Sale of gargets for blood pressure monitoring and education on how to use them to monitor their response to treatment at home.

   Consequently, collaboration or community pharmacy with the public sector in terms of referral and further management is necessary. What is proposed as new is a service agreement with the public sector whereby patients who would otherwise be seen at the PHC clinic come to the retail pharmacy to receive care and treatment at the cost of public sector. This is already being done through contracted service in many countries; it just needs to extend to the resource-limited countries. For example, in England, the study of Albasri et al. showed that there is strong trial evidence for the involvement of community pharmacy in the long-term management of hypertension [74]. Systematic reviews and meta-analyses of these trials demonstrate that when compared with usual care, the results consistently show a 6–7 mmHg reduction in systolic blood pressure [74].

2. The PHC facilities that are run by nurses could also include the services of pharmacists, who have competencies to run pharmacy-led chronic disease clinics. This addition will complement the skills of nurses and give them time to manage other programmes in the PHC facilities such as mother and child services immunisations. If Lesotho has high disease burden, doing similar activities have to be avoided because poor results in maternal mortality rates, infant mortality rates and failure in other programmes will prevail. It is suggested that pharmacist-led chronic disease management be included in the policy and treatment guidelines.

   The study of Buis et al. considered primary care patients with uncontrolled hypertension whose blood pressure was effectively reduced by a pharmacist-led mobile health (mHealth) intervention which was intended to promote the home blood pressure monitoring and clinical pharmacist management of hypertension [75]. The data in this study also support the feasibility and acceptability of these types of interventions for patients and providers [75].

   In Sweden, when collaboration between community pharmacy and primary health care was reflected, it was viewed as a golden opportunity [76]. The primary health care has strategic plans and national policy documents which do not include community pharmacy as a partner, and this is considered as a major challenge [76]. This was a similar case to Ghana community pharmacy and primary health care [69]. Figure 2 summarises what the pharmacist will be doing at the community pharmacy and at the PHC clinic if he/she works for the facility. This has to be done through government policies and be properly regulated through relevant laws.

Figure 2.

Summary of the role of a pharmacist in the management of hypertension in the community pharmacy and primary health care clinic.

9. Conclusion

Primary health care is a good place to manage preventable diseases. Treatment outcome can be monitored at the PHC level and lifestyle modification can be instituted according to patients’ needs. There is evidence that involvement of pharmacist at the community pharmacy and at the primary healthcare facility can improve treatment outcome of hypertension.

Therefore, it is recommended that there should be policy change that allows for involvement of pharmacy in the management of hypertension.

Acknowledgments

I would like to thank the Department of Pharmacy National University of Lesotho and Senkatana Project administrator for her assistance. I would also like to thank my daughter and sons who are always there and making my life worth living.

Conflict of interest

The authors declare no conflict of interest.

Acronyms and abbreviations

BP

Blood pressure

BPT

Blood pressure telemonitoring

CDM

Chronic disease management

CHAL

Christian Health Association of Lesotho

CVDs

Cardio Vascular Diseases

DHMTs

District Health Management Teams

GDP

Gross Domestic Product

GoL

Government of Lesotho

IPHC

Integrated primary health care

mmHg

Millimetres of Mercury

MoH

Ministry of Health

MOPH

Ministry of Public Health

NCDs

Non communicable diseases

OTC

Over the counter

PHC

Primary health care

SACU

Southern African Customs Union

UN

United Nations

UNICEF

United Nations International Children’s Emergency Fund

VHW

Village health workers

WHO

World Health Organisation