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Primary Health Care
As initially planned, PHC brings health promotion, disease prevention, cure and
care together in a safe, effective and socially acceptable manner to the community [].
The report by Stender et al. further discusses the skills that are acquired and the training that healthcare workers at the PHC level receive []. 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 [].
. Healthcare human resources
Health worker density is the most widely used indicator to determine available
human resources []. The WHO has set a density indicator of . healthcare
professionals per population as the minimum threshold for access to public
healthcare services [ ]. 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
[]. Zimbabwe’s health worker density at . per of the population is higher
than those of Sierra Leone and South Sudan but is still less than the WHO’s density
benchmark []. In Botswana, according to Nkomazana et al., the health worker
density is . doctors and . nurses per , of the population []. In Lesotho,
however, health workforce is challenged to meet the needs of its population. The
nursing and midwifery workforce is . per , compared with neighbouring
South Africa’s per , and per , for the Africa region [ ].
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 [].
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 was . Over
half () of nurse and midwife posts remain vacant in rural areas []. At the end
of the financial year, only 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 []. 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.
. 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 [ ]. 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
[]. 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 depicts the scope of pharmacy in Lesotho in terms of regulation,
education practice and research.
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DOI: http://dx.doi.org/10.5772/ TexLi.101431I
. Disease burden
The country is faced with enormous health challenges; as nearly one-quarter
of adults years of age are living with HIV (.) [− ], and Lesotho is
considered to have the world’s second highest tuberculosis incidence rate at
cases per , population [ ]. Lesotho as a country also has one of the ,
highest maternal mortality ratios in the world at per , live births, with
a lifetime risk of maternal death at in []. According Lesotho Demographic
and Health Survey (LDHS), there were of women and of men aged
– who have hypertension [ ]. One in five women and one in seven men with
hypertension ( of all women and of all men age –) have their hypertension controlled with medication [].
. 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 []. The global prevalence of hypertension
in adults aged years and over was around . for men and . for women
in []. Based on the statistics of hypertension reports for the past years,
the WHO predicts that, by the year , almost of the world’s hypertension
population will be found in developing countries []. However, the global action
plan has a target of a reduction of the global prevalence of hypertension [].
Nonetheless, recent statistics on the prevalence of chronic diseases in Lesotho
indicate that the presence of hypertension was reported to be at in [].
Inevitably, hypertension ranks among the top causes of morbidity and mortality
and is the third-most common cause of hospital admissions in the country [, ].
Figure 1.
The scope of pharmacy practice in Lesotho.
152
Primary Health Care
An accurate measurement of blood pressure with a well-fitting calf remains an
important part of diagnosis of primary hypertension . In an adult, the normal []
blood pressure is said to be /mmHg []. A definite diagnosis of hypertension
is when their blood pressure reading is above / mmHg on three consecutive
clinical visit within two days up to a maximum of days in between [, ]. 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 [].
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 []. 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 []. 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 [].
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) []. Patients with uncontrolled blood pressure despite medication adherence and lifestyle changes are referred to the secondary level of care for
further investigations and management [].
The effectiveness of hypertension treatment and experiencing its benefits relies
critically on strict compliance to treatment instructions []. 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 [].
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 [].
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 []. 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 [].
Hacihasanoglu and Gozum report that in Turkey, of hypertension patients
did not take their medications as prescribed and defaulted on their appointment dates []. In contrast, Mafutha and Wright argue that medication-taking
behaviour is not affected by failure to comply with follow-up appointments to collect medications []. Their study at primary healthcare clinics in Tshwane, South
Africa, reported that of patients were compliant regarding medication-taking,
yet were non-adherent to follow-up appointments []. 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 [, ].
Consequently, a particular factor associated with non-compliance of an individual
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hypertensive patient should guide interventions that improve appointment keeping
compliance [, ].
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 [ ].
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 []. 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 [ ]. 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 [].
In their study, Wells et al. found that hypertension appeared to be one of the
highest risk factors of heart failure [ ]. Hypertensive patients have a higher risk
of having heart attack, heart failure, stroke, kidney disease than normotensive
people []. 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 []. 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 [ ]. 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 []. The development of management plans must take into account
patients’ needs and preferences as chronic patients are said to be their own primary
carers []. According to Siantz et al., in order to minimise functional limitations
and disability, effective management of chronic conditions requires behavioural
and lifestyle adjustments []. Therefore, an appropriate theoretical framework fitting the health problem of interest to change behaviour needs to guide the planned
organisational interventions [].
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 []. It is believed that informed patients improve their
decisions by collaborating with their healthcare providers []. 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 []. 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 [ ]. The study of Wagner et al. suggested the need to transform a health
154
Primary Health Care
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 [].
. 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 []. However, it was suggested that there is a
need to provide more staffing to address staff shortages and reduce patients waiting
times at facilities []. 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 []. 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 []. 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 [].
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 []. However, the national policy on
prevention and control of chronic NCDs acknowledges the role of primary community facilities with no mention of community pharmacies [].
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 [ ]. Nevertheless, the requirements for meaning-
ful participation should be considered and realised which include the relevant
staffing compliment, health promotion skill, pharmacy setting and referral systems
[ ]. Moreover, this service requires the constant presence of a pharmacist, screen-
ing space with privacy for counselling, staff training and referral linkages with the
nearest health centre/clinic/hospital for referrals [ ].
Furthermore, Omboni evaluated blood pressure telemonitoring (BPT) programmes involving a pharmacist; it was stated that this may require investment
in laboratory monitoring and technologies [ ]. 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 []. 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 [].
. 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.
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Use of Primary Healthcare Facilities for Care and Support of Chronic Diseases: Hypertension
DOI: http://dx.doi.org/10.5772/ TexLi.101431I
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, noncommunicable diseases, health awareness and essential medication []. Based on
the above scenarios, in order to prevent disease progression, hospitalisation and
poor prognosis of patients with hypertension, the following are proposed:
. 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 [ ]. Systematic reviews and meta-analyses of these trials
demonstrate that when compared with usual care, the results consistently show a
–mmHg reduction in systolic blood pressure [ ].
. e PHC facilities that are run by nurses could also include the services of
pharmacists, who have competencies to run pharmacy-led chronic disease clinics. is addition will complement the skills of nurses and give them time to
156
Primary Health Care
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
[]. The data in this study also support the feasibility and acceptability of these
types of interventions for patients and providers [].
In Sweden, when collaboration between community pharmacy and primary
health care was reflected, it was viewed as a golden opportunity []. 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 [].
This was a similar case to Ghana community pharmacy and primary health care [].
Figure 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.
. 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.
Figure 2.
Summary of the role of a pharmacist in the management of hypertension in the community pharmacy and
primary health care clinic.
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Use of Primary Healthcare Facilities for Care and Support of Chronic Diseases: Hypertension
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
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DOI: http://dx.doi.org/10.5772/ITexLi.101431
Acknowledgements
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.
Primary Health Care
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