Management of Hypertension in Zanzibar
To develop a service to ensure comprehensive detection, lifestyle intervention and effective medical management of hypertension in Zanzibar, with the ultimate aim of decreasing rates of stroke, ischaemic heart disease & other complications of hypertension.
HIPZ Hypertension Working Party:
Dr Jonathan Rees – General Practitioner and Trustee of HIPZ.
Mr Ruaraidh MacDonagh – Consultant Urological Surgeon, founder and Chairman of HIPZ.
Dr Mike Spencer-Chapman, HIPZ doctor and Trustee.
Mr Mohammed Jiddawi – Principal Secretary to the Minister of Health, Zanzibar and Consultant Surgeon.
Background to HIPZ
HIPZ (Health Improvement Project Zanzibar) is a UK-registered charity established in 2006 by Mr Ru MacDonagh, a consultant surgeon based in the UK. The other trustees of HIPZ are mainly UK doctors who have worked in Africa, along with trustees with other relevant experience. Having worked for several years in Zanzibar and Tanzania, Ru has developed strong links in Zanzibar with both the Health Sector and the Government. It was an approach for assistance from Dr Jiddawi, Principal Secretary to the Minister of Health that led to the creation of HIPZ. A Memorandum of Understanding was signed in 2007 handing over the running of Makunduchi Hospital to HIPZ for ten years, with the explicit aim that HIPZ should improve the provision of healthcare in a hospital that was desperately inadequate. This collaborative venture has proved to be extremely successful in its first six years. As a direct result of the transformations made at Makunduchi Hospital, the President of Zanzibar requested that HIPZ become involved in a larger and even more challenging hospital at Kivunge. This will mean that HIPZ will be delivering healthcare to approximately 250,000 people in areas that formerly had very little healthcare provision – and in total a quarter of the population of Zanzibar.
The innovative HIPZ model
The Government of Zanzibar entrusted Makunduchi Hospital (in 2007) and Kivunge Hospital (in 2012) to HIPZ for ten years each, with the explicit aim that HIPZ improve the provision of healthcare in these hospitals which were barely functioning. As far as HIPZ can establish, the arrangement whereby a government hands over the running of a hospital to an NGO for a protracted period and with the explicit aim of improving services, is unique. The HIPZ model is simple and innovative, and works across the whole healthcare facility rather than working in vertical programmes on specific illnesses. Staff, salaries and basic services are still provided by the Ministry of Health, thus retaining their statutory responsibility, but the volunteer doctors, clinical services, management, renovation, new building, procurement of equipment and medical supplies, and most critically, training are undertaken by HIPZ. Our approach is based on embedding ourselves in the day-to-day running of the hospital to forensically examine where problems are occurring. Only by understanding what is happening on every level – from drug supplies to waste disposal to staffing issues and patient care – can the changes needed to make sustainable improvements take place. A fundamental and intrinsic part of the HIPZ model is long-term financial and clinical sustainability and ultimately a return to full Zanzibari – delivered services. Sustainability is built in to the provision of all of the clinical and administrative services developed by HIPZ. The eventual withdrawal of HIPZ will be undertaken in a progressive, planned and managed way once the requisite trained staff and systems are embedded. HIPZ intends to write up the model based on the outcomes to date to be published and peer reviewed by the medical community. We are keen for the model to be disseminated to a wider audience as its effectiveness could be replicated elsewhere.
Further background to the work of HIPZ is provided in the Appendix (page 10 & 11)
Increasing urbanisation and increased exposure to a range of risk factors has led to a huge rise in the incidence of non-communicable disease in Africa. A BMJ editorial in 2005 reported that cardiovascular disease ‘has reached near epidemic proportions in Africa’, with the WHO in 2002 reporting that almost 10% of deaths were due to cardiovascular disease, with hypertension as the most prevalent underlying cause. This figure will only have increased in the decade that has passed, as lifestyles continue to change.
CVD presents in a number of ways – angina and myocardial infarction are seen less often in Africa, but stroke, cardiomyopathy and heart failure are common presentations. Decreasing the incidence of CVD requires a range of interventions – particularly the identification and management of well-known risk factors such as smoking, obesity, poor diet and lack of exercise, but also the optimal management of predisposing conditions such as hypertension and diabetes.
Prevalence of hypertension in Zanzibar:
There is a striking lack of robust published data regarding the prevalence of hypertension within Zanzibar. The Zanzibar Health Sector Reform Strategic plan 2007 – 2011 states ‘there is no data on the extent of hypertension in Zanzibar except that reported by Mnazi Moja Hospital (MMH). In 2005, 735 cases of hypertension were admitted to MMH. A quarter of these suffered cardio-vascular accident (CVA), possibly due to hypertension or hypertensive vascular diseases’.
Unpublished research submitted as part of a Master’s thesis in 2005 examined the prevalence of hypertension in Southern District. The study was based on a cross-sectional survey of hypertension and related risk factors among a randomly selected group of 323 adults in the age group 20-64 years. The overall prevalence of hypertension was 27.2% (based on WHO definition of hypertension as >140mmHg systolic or >90mmHg diastolic). The prevalence of hypertension among males and females were 24.7% and 29.5%, respectively. In both males and females, the prevalence of hypertension increased with age.
Further unpublished data comes from the recently completed STEPS study – this was a survey of risk factors for non-communicable diseases (obesity, diet, blood pressure, activity levels etc) carried our across Zanzibar by DANIDA (n=2639, aged 25-64). Hypertension was found to be extremely prevalent, with an overall rate of 33% (males 37%, females 29%). However, this is based on the WHO definition of hypertension as blood pressure >140 systolic or >90 diastolic (i.e. mild hypertension), which may prove to be an inappropriate starting point for treatment of hypertension in Zanzibar. Moderate to severe hypertension (>160 systolic or >100 diastolic) was also highly prevalent at 16.2% – in the over 45 year old population overall prevalence of moderate to severe hypertension was 34.4%, compared to 9.4% in the under 45 year old population. Prevalence in the male and female population was roughly equal (33.2% and 35.9% respectively in the over 45 year olds).
As a result of these findings, the most recent HIPZ Annual Review stated that the improvement in the management of hypertension in Zanzibar was a priority for 2014.
Audit of hypertension management at Makunduchi Hospital – September 2013:
Between June and September 2013 an audit was carried out at Makunduchi Hospital on behalf of HIPZ. 215 patients were identified who were being managed for hypertension in the outpatient clinic. The main findings were:
- Female preponderance – 74% of patients were female, 22% male and 4% unrecorded gender. This is in keeping with usage of the hospital by a predominantly female patient population and reflects a significant unmet need of large numbers of male hypertensives unidentified in the community.
- Median age of patients was 55 years old. Younger patients had no record of investigations having been performed for secondary hypertension.
- Median systolic blood pressure was 170mmHg, with 39% of patients having a systolic >180mmHg (figure 1). It is important to remember that this poor control of blood pressure is seen despite the fact that this is a cohort of patients supposedly treated for hypertension, and shows the likely scale of the problem in the remaining untreated population.
Figure 1: Range of blood pressures in Makunduchi outpatient clinic 2013.
Problems facing HIPZ in setting up a hypertension service:
The limited prevalence data shows that hypertension is a major health problem in Zanzibar. The audit data shows that even in those patients who are known to be hypertensive, management is poor and only a small minority are successfully treated to an acceptable target blood pressure. There are a number of difficulties that are faced in trying to remedy this situation:
- Poor understanding in the community of hypertension as a risk factor for cardiovascular disease or of the lifestyle measures that can be taken to reduce risk.
- Ad hoc identification of hypertension in the community means that the vast majority of hypertensive patients remain unidentified and therefore untreated.
- Poor understanding by the clinical staff at Makunduchi and Kivunge hospitals of the management of hypertension, including the concept that treatment needs to be continued in the long term and not stopped once a target blood pressure is reached.
- Lack of availability of anti-hypertensive medication on Zanzibar. This is a fundamental problem and is dealt with in more detail in the next section.
- Achieving long term sustainability for the hypertension service, particularly with regard to financing of long term medication.
Current anti-hypertensive prescribing:
Current regulations within Zanzibar mean that when a patient is identified as having hypertension, they can be prescribed medication from the hospital pharmacy for the first 2 weeks. This medication is funded by the Ministry of Health, and is susceptible to lack of availability of particular drugs on a regular basis, according to ‘stock outs’ at the central government stores. After this 2 week period, patients are issued prescriptions to be filled at local private pharmacies, and patients are thus exposed to significant mark ups in cost, which makes long term medication unaffordable for the majority. This plays a huge part in lack of blood pressure control in the majority of patients.
HIPZ has recently (2012) implemented a new protocol for management of hypertension – the suggested drug regime is detailed in figure 2.
This protocol is an attempt at compromise between best practice, drug availability and drug cost. However, the recent audit at Makunduchi showed that 49% of patients were not being managed according to this protocol. The commonest omission was of an ACE inhibitor (Captopril), with the combination of bendroflumethiazide plus atenolol the most commonly prescribed. Figure 3 outlines the frequency of drugs prescribed in the Makunduchi hypertension clinic. The reasons for this were varied, but most common reasons found were financial (i.e. patient unable to afford the cost of the drugs) or lack of availability in pharmacy of the suggested medication regime.
The aim of this grant application is to enable HIPZ to devote time and resources to setting up and running an efficient service for the management of hypertension at Makunduchi and Kivunge Hospitals in Zanzibar. We also aim to further understand the nature of hypertensive disease and the prevalence of its complications in our treatment population. This requires:
- Staff training: the audits carried out show that the Clinical Officers, who are predominantly responsible for managing this service, have a poor understanding of hypertension and of medical management. There is considerable deviation from suggested treatment pathways and failure to step up treatment for those patients not reaching blood pressure targets.
We propose to run a series of practical training sessions such that the clinicians at Makunduchi and Kivunge become familiar with the nature of hypertensive disease and the rationale behind its management, as well as the practicalities of treatment.
- Efficient sourcing of anti-hypertensive medications: theoretically the government supply all the anti-hypertensive medications on our protocol, which are then free for all patients. However, the supply chain is currently highly erratic and there are frequent stock-outs.
We hope to address the drug supply issue in two ways. Firstly, to temporarily plug any gaps in drug supply by buying the drugs ourselves. This will allow us to run an effective clinic for a 2 year trial period. During this time we hope to demonstrate improvement in control of hypertension in our clinic populations by regular re-auditing: as well as improving the standard of care for our patients, it will act as a ‘proof of concept’, showing the government the importance of a reliable supply of drugs in providing meaningful care. During this time, we will continue to work with the government in improving the drug supply chain – work which is already underway.
- Access to basic investigations: performing a baseline set of screening investigations for all patients enrolled in the clinic including a urine dip, renal function tests, chest x-ray and an ECG. As well as helping manage individual patients this will be a valuable research project providing much needed data on the prevalence of the complications of hypertensive disease as well as pick up possible cases of secondary hypertension (in the case of renal disease). These investigations will enable us to identify high risk patients with evidence of end-organ damage, who may require further investigation such as echocardiography, and will need much closer attention to effective blood pressure control.
- Upgrading clinics infrastructure/ equipment: Currently basic equipment for the running of the clinic – e.g. reliable supply of clinic proformas, filing of patient notes, BP cuffs for a range of arm sizes – are lacking. We would like to invest in basic office infrastructure to allow the clinic to function effectively e.g. photocopier, files, filing cabinets, blood pressure monitoring equipment.
- Long term sustainability of medication supply: It is not feasible in the long term for HIPZ to provide anti-hypertensive medications (and those for other long term conditions) for free to the population of Zanzibar. Thus, a sustainable model is required once HIPZ has sourced a reliable supply. The proposed model is one of cost-sharing, with HIPZ purchasing the drugs and selling them on to the patients at cost price. This model has been successfully used in other aspects of HIPZ work at Makunduchi and Kivunge. For the hypertension service this may require some infrastructure changes, i.e. the development of a separate pharmacy area for dispensing of cost-sharing medications.
- Clinical support costs: in order to effectively run this project, considerable input will be required from a doctor funded by HIPZ, who will be specifically tasked with leading on this work from Zanzibar. Our doctors work on a voluntary basis and costs of flights to and from Zanzibar are covered by HIPZ. However, various costs such as housing and transport need to be covered.
The prevalence of high blood pressure and associated risk factors in South District, Unguja, Zanzibar: A cross-sectional survey. Dr S. Salmin. Masters degree in International Health, University of Copenhagen.
 Personal communication from Jutta Jorgensen, DANIDA November 2011.