Non-communicable diseases

The global prevalence of all leading chronic non-communicable diseases is increasing, with the majority occurring in developing countries and projected to increase substantially over the next two decades. PS Kenya implemented 24 months of a private sector model in AstraZeneca’s HHA project that sought to improve knowledge and awareness of hypertension, enhance the competence of those offering hypertension services, and increase access to affordable and quality antihypertensive medications. This project was implemented through the Tunza Family Health Network, a social franchise of private providers who offer primary health care services and serve the low-income population.

The program is targeted to Kioko, who represent the at-risk population. Kioko is a male aged 30 years and above who lives in a high population settlement in Nairobi or its outskirts. He is married with two children and is employed in a local school. Kioko indulges in social activities like “nyama choma” and social drinking, making him at risk of hypertension. He fears losing his job, and health is not a top priority until a family member gets sick, and he usually visits a chemist to get drugs. Kioko has very poor health-seeking behavior compared to his female counterpart. The program also sought to reach males and females equally.

Patient Awareness of hypertension

It took a long time for a patient to acknowledge and actively manage their condition on their own, even after discovery. This was influenced by the asymptomatic nature of the disease and health not being a key priority. Kenyans were faced with other front-of-mind challenges, such as feeding their family and paying school fees.

Private sector learning. There is need for:

Long-term, integrated social behavior change communications and interventions are needed to address different stages of the patient pathway. This acknowledges that the path to behavior change is not linear, and there is a need to invest in operational research to determine the barriers to adopting hypertensive care along the journey.
A myriad of demand creation activities is necessary to create awareness in the general population. Implementing “Kioko”-specific activities, such as workplace outreaches, are key to managing males and females equally. Medical camps/outreaches with a clinician on board to administer treatment on-site are preferred because of their high ability to link patients to treatment. The program demonstrated high linkage rates when the “Reach, screen and treat” – Medical camps with clinicians on board approach was implemented, increasing aggregate linkage rates from 28% to 52.7% within demonstration and extension phases, respectively.
High-caliber Community Health Volunteers (CHVs) are essential to complement the private sector cadre of clients. CHVs require a rigorous recruitment and capacity-building process covering messaging and Monitoring & Evaluation (M&E). They also require support supervision to ensure high-quality sessions are being conducted.
Incentives are crucial to motivating frontline workers to follow up on patients screened and found to have elevated blood pressure. The project demonstrated an increased linkage of up to 113% by applying monetary incentives.

Patient management of hypertension

There is no cure for hypertension. Treatment can start with lifestyle modification and progress through different medicine offerings. Until a patient is fully aware and understands the need to proactively manage their condition, they are unlikely to turn up to the clinic without prompting.

Project learnings

Active quality assurance and provision of hypertension (HTN) capacity-building activities, in addition to task shifting hypertensive care to nurses, will support the increasing number of Kenyan adults in accessing hypertension treatment. Seventy-four percent of the project sites were operated by nurses.
The development of appropriate monitoring tools enabled the collection of client-level data to ensure accountability for all people screened through to diagnosis and adherence. This level of data facilitated follow-ups along the patient pathway. Due to the volumes of data, the program had five dedicated staff to ensure monthly reporting was achieved.
There is a need for providers to access and use monitoring data to manage patients, informing management and retention strategies such as provider-initiated follow-up (text, calls) and MOPC clinics to manage patients. PS Kenya would analyze and share monthly data with the providers to inform progress, focusing on addressing lost-to-follow-ups to ensure adherence and better health outcomes.
Private providers require business support on financial management, supply chain management, and customer care as key skills needed for a successful private practice. Top Care nursing home, after receiving business support, set out to improve hypertension service within their clinic, focusing on implementing MOPC clinics once a week in addition to investing in equipment and other operational changes. After a duration of three months, the clinic demonstrated astronomical profits of over 1000%.
Anecdotal information indicates that patients prefer not to be put on drugs initially due to reasons such as perceived fear of the expense of the drugs, in addition to the fear of being on drugs for the rest of their lives.

Supply Chain Management.

Following the development of the Ministry of Health (MOH) Hypertension protocol, sites may experience shortages of medicines, which can interfere with the management of hypertension, even though patients can afford them.

Project learnings

There is a need for active supply chain management, specifically pooled procurement to favor small providers who are disadvantaged in accessing high-quality medication. The project set up seven stockists within areas of implementation, establishing a hub and spoke model where smaller facilities would order and pay for their stocks from the stockist, reducing cases of delayed deliveries from central distribution.