Table 2 Challenges and opportunities for hypertension services captured by stakeholder level and health system building block

Service delivery

- Insufficient coverage and limited service unit infrastructure

- Lack of laboratory capacity

- Different models of service delivery implemented at the primary care level

- Copies of treatment guidelines often not available

Patients are uncertain about how to manage their disease and when they need to seek care

Human resources

- Need for enhanced teams at the primary care level

- High staff turnover

- Limited opportunities for professional growth; short-term contracts

- Limited training on hypertension and in-service “cascade” trainings miss frontline providers

Limited consultation with community members (leaders, traditional healers) in some settings

Information systems

- Lack of a standardized clinical encounter form

- Undercounting of people with hypertension in clinical encounters

Some but not all sites have lists of patients with hypertension & other chronic conditions

Patients do not keep track of their blood pressure

Medications and technologies

Hypertension medications are not consistently available (if available, primarily Enalapril)

- Often lacking medications for hypertension (if available, primarily Enalapril)

- Lack of blood pressure monitors in some settings

Patients use traditional medicine in addition to pharmaceutical medications

Financing

Public health system is underfunded

Health Areas manage the budgets (not the local, district level)

Patients are unable to afford medications (when there are stock-outs)

Governance & leadership

Need for increased capacity for intersectoral collaboration to address chronic diseases

Opportunity for increased coordination between community members and providers

Patients with hypertension at times participate in diabetes clubs; eagerness to become more actively involved in their care