Identifying solutions to bottlenecks in hypertension service delivery: Insights for improving case detection in Tajikistan

Hypertension, a significant risk factor for ischemic heart disease and other chronic conditions, is the third-highest cause of death and disability in Tajikistan. Thus, ensuring the early detection and appropriate management of hypertension is a core element of strategies to improve population health in Tajikistan. For a strategy to be successful, it should be informed by the causes of gaps in service delivery and feasible solutions to these challenges. The objective of this study was to undertake a systematic assessment of bottlenecks in service delivery for hypertension within primary health care in Tajikistan and define appropriate solutions.Methods Our study drew on the cascade of care framework to examine patient progression through the recommended stages of care. We triangulated data from household surveys and facility registries to describe the cascade. Focus group discussions with local stakeholders identified the determinants of discontinuities in care. Drawing on global empirical evidence on effective interventions and stakeholder judgments on the feasibility of implementation, we developed recommendations to improve hypertension service


Abstract Background
Hypertension, a significant risk factor for ischemic heart disease and other chronic conditions, is the third-highest cause of death and disability in Tajikistan. Thus, ensuring the early detection and appropriate management of hypertension is a core element of strategies to improve population health in Tajikistan. For a strategy to be successful, it should be informed by the causes of gaps in service delivery and feasible solutions to these challenges. The objective of this study was to undertake a systematic assessment of bottlenecks in service delivery for hypertension within primary health care in Tajikistan and define appropriate solutions.Methods Our study drew on the cascade of care framework to examine patient progression through the recommended stages of care. We triangulated data from household surveys and facility registries to describe the cascade. Focus group discussions with local stakeholders However, there are significant gaps in hypertension detection and management in Tajikistan. In a 2013 survey of male and female adults in Tajikistan by the World Bank, only 10 percent of hypertension cases had been diagnosed, and 42 percent of respondents had ever had their BP measured. Furthermore, only 10 percent of diagnosed cases had attained BP control, indicating that their management could be improved [3]. In a nationally-representative survey of women aged 15 to 49 years carried out four years later in 2017, these challenges persisted. Only 17 percent of respondents with hypertension were aware of their condition and actively managed their BP, while 60 percent were unaware of their hypertensive status [4]. Cases of undiagnosed and inappropriately-managed hypertension represent missed opportunities to address the growing burden of cardiovascular diseases in Tajikistan. Hence, the Government of Tajikistan and other stakeholders have invested in policies and programs to address gaps in service delivery for hypertension.
In Tajikistan's National Health Strategy for 2010-2020, there is a clear focus on   decreasing the burden of NCDs by increasing preventive activities and promoting proactive management at the primary health care (PHC) level [5]. Furthermore, the NCD Strategy for 2013-2023 aims to reduce the prevalence of hypertension by 3 to 5 percent between 2017 and 2023 [6]. There are also national strategies focused on population health measures to reduce the risk for cardiovascular diseases and hypertension, by promoting physical activity and healthy eating, and to facilitate the appropriate management of complications of hypertension. Furthermore, Tajikistan has national clinical guidelines for hypertension diagnosis and management at the PHC level, and prescriptions have been oriented towards generic drugs by a ministerial order [7].
There have also been concerted efforts to translate these policies into practice.
Significantly, since 2013, in partnership with the World Bank, the Tajikistan Ministry of Health and Social Protection (MoHSP) has implemented results-based financing (RBF) and collaborative quality improvement (CQI) through the Health Services Improvement Project (HSIP) to increase the coverage and quality of PHC for selected conditions, including hypertension. The investment focuses on 400 PHC facilities in eight districts in Khatlon and Sogd Oblasts. Through RBF, facilities and health care providers receive monetary incentives if they attain service coverage targets, including for the diagnosis and management of hypertension. About 200 clinics, through CQI, also adopted a system for monitoring and improving service delivery for hypertension and maternal and child healthcare, including 1) guideline-informed flowsheets to facilitate evidence-based diagnosis and treatment, 2) electronic medical records to monitor patient care, 3) monthly reviews of patient management and opportunities to improve services, and 4) data aggregation tools to assess facility-level trends [8].
Despite these strategies and investments since 2010, the 2017 DHS revealed that there are persistent gaps in the diagnosis and proactive treatment of hypertension in Tajikistan.
Thus, in partnership with the MoHSP, the World Bank undertook a systematic assessment of service delivery for hypertension in PHC, embedded within the ongoing investments in RBF and CQI, to assess service delivery bottlenecks and identify appropriate solutions to these bottlenecks. This effort is an example of implementation research, which integrates systematic assessments within ongoing programs or policies to enable learning from realworld successes and failures. Through partnerships with local stakeholders, implementation research can ask the right questions, identify context-specific causes, and delineate feasible solutions, while drawing on the global evidence on what works in other contexts. A recently-published open-access report of the MoHSP and World Bank team summarizes the results of this assessment of service delivery of hypertension [9].
In this paper, we review the process of describing the cascade of care for hypertension.
The cascade of care framework has been used in a wide range of contexts to describe retention of service users in the continuum of care for conditions requiring multiple provider-user contacts, including HIV, tuberculosis, hypertension, and diabetes [10], [11], [12], [13], [14]. These studies provide useful descriptions of discontinuities in care use and correlations with patient characteristics. Our paper builds on these analyses by drawing on the framework and a mixed methods approach to understanding these gaps in continuity of care embedded in real-world programs. Our paper may provide useful lessons for practitioners in similar contexts who aim to use the cascade of care to develop actionable insights for improving service delivery.

A. Describing the Hypertension Care Cascade
The management of hypertension involves multiple contacts between the provider and service user-screening, diagnosis, treatment, and monitoring-to achieve and maintain BP control, which is essential to reducing complications and preventing mortality. The cascade of care disaggregates these contacts and provides a useful framework for examining patient progression and identifying drop-offs, that is a discontinuity of recommended care by service users along the cascade of care (Figure 1).
We defined critical stages in patient-provider interactions from pre-diagnosis to the initial attainment of BP control and their accompanying measures: as diabetes co-morbidity, as specified in Figure 2.
We drew on existing data sources, including routine health information systems and household surveys conducted through the Demographic and Health Survey and a World with a pregnancy in the past two years, or a family member above the age of 40 years.
While these criteria imply that the survey may not have been representative of the adult population, it was the most recent objectively-measured rather than self-reported BP data within the facility catchment areas. In total, this survey provided data on 8,443 adults in hypertension diagnosis, monitoring, and blood pressure control were limited to the CQI database and were unavailable for the broader population. The CQI database also documented for the registered hypertension cases the prescribed medicines, a diagnosis of diabetes, and body mass index. BP results within patient records were categorized by level of severity and by timing (ever/last three months).
By triangulating data sources, including household surveys and facility registries, we were able to estimate the proportion of hypertensive individuals who initiated care and were retained along each step of the care cascade. Graphical descriptions of the cascade of care in both Oblasts, by age group, were presented to facilitate assimilation by the target policy and practitioner audience. The quantitative data on retention along the cascade of care illustrated the magnitude of the burden of undiagnosed hypertension and the poor treatment outcomes among diagnosed cases, and motivated discussions on the causes of these gaps.

B. Understanding the Determinants of Retention in Hypertension Care Cascade
To understand the context-specific reasons for drop-offs along the hypertension care cascade, we held focus group discussions (FGDs) with service users, health providers, and health care administrators in Khatlon and Sogd Oblasts. Service users included male and female adult patients from age 18 years and above, and pregnant women with a diagnosis of hypertension. We recruited health providers at the district level and health administrators who were heads of rural health centers (RHCs) or representatives of the Oblast Health Department. In total, we included 208 participants in 18 FGDs (Table 1).
Insert Table 1 The FGD guides were developed collaboratively by technical experts within the World Bank and Tajikistan. World Bank experts in service delivery, implementation research, and clinical medicine drafted discussion guides with probes to identify the causes of drop-off and retention at each stage in the care cascade, which were reviewed and refined for wording by local experts involved in hypertension care. The discussion guides were also reviewed by local stakeholders involved in the implementation of the ongoing investment project for completeness and by other facilitators of the FGD to ensure that the translated guides were worded to be consistent with the desired meaning.
The final FGD guides were organized by stage in the care cascade and concluded with an invitation to discuss how high BP could be avoided, that is primary prevention measures.  provider-, and administrator-level perspectives, which are fully described in a recentlypublished report [9].

C. Identifying Fit-for-Purpose Solutions to Improve Retention in the Hypertension Care Cascade
We defined fit-for-purpose solutions as interventions that met three criteria: 1) focuses on a barrier to or facilitator of retention in hypertension care identified in the diagnostic process; 2) empirical evidence of effectiveness in the published or grey literature, and 3) perceived by local stakeholders as applicable to PHC in Tajikistan.
Based on the identified barriers to and facilitators of retention in hypertension care, the characteristics of appropriate solutions were defined as illustrated in Table 2 below: Insert Table 2 In October 2018, we conducted a review of interventions aimed at addressing the identified barriers in the hypertension care cascade. Using PubMed, we searched for English or English-translated articles published between 2000 and 2018 that evaluated an intervention's impact on a care cascade-related metric, such as percent referred to care, percent adherent to medication, and change in BP. Search terms are displayed in Figure 3.
We screened the abstracts of resulting articles and retained those that met our inclusion criteria of evaluating a program or intervention's measurable hypertension care cascaderelated outcome. We extracted the following information into a spreadsheet template: the country the intervention took place in, the target population, care cascade focus area, type of program or policy, health service level, health personnel involved, sample size, primary and secondary outcomes, and any available cost information. Whether Insert Table 3 Discussions with key stakeholders revealed that screening and diagnosis rates are negatively affected by a lack of understanding of hypertension in the general population; ambiguous clinical protocols; the low priority given to hypertension screening; and the limited capacity to reach rural and remote communities. Prenatal care and community screening were identified as avenues that have been successful at identifying undiagnosed cases. We review these themes below.
It is common for hypertensive individuals to be unaware of their condition and for the first encounter with the health facility to occur following complications of chronic hypertension.
The connection between high BP and these complications, including cardiovascular diseases, is also not well understood by individuals with hypertension.

"Patients do not come for screening because they don't know the risks and negative consequences of hypertension" (Participant 5, Health Administrator, Khatlon Oblast).
Even in the absence of information barriers, communities face costs in terms of money and time to obtaining a screen for hypertension in the health facility or at home.
Households in remote areas are often also located a far distance from the nearest health center and may find the facility challenging to reach. These locations are also less likely to participate in community screening. Among rural populations that may not be remote, farm work during the day may prevent individuals from being screened by healthcare workers, even at home.
On the supply-side, particularly in rural and remote areas, an insufficient supply of equipment and human resources has limited the ability of service providers to screen their catchment population for hypertension, at home or in the facility. Sphygmomanometers are not replaced and calibrated regularly, reducing their accuracy in measuring BP. A high caseload for limited health workers implies that routine screening in the community and facility is de-prioritized. Furthermore, Current protocols have an unclear scope of work for each health care level, lack clear guidance for service delivery in remote and rural areas, provide insufficient information on case finding, treatment adherence and common barriers to adherence, and do not consider the perspectives of providers and service user.
There are also no readily-available guides that providers could refer to when needed. In terms of policy and programming, health administrators were unaware of the high hypertension burden and the levels of under-diagnosis. As analysis related to the burden of hypertension, diagnosis, and management of cases, was not routinely done, these statistics could not inform strategic plans for the health sector. In addition to constraints from limited financing, the NCD strategy, which is the guiding policy document, does not include specific recommendations to improve service delivery for hypertension.  [18].
Finally, introducing easy-to-use job aids can address concerns among providers about the relevance, accessibility, and clarity of guidelines for care. Job aids can provide practical and evidence-based guidance to health workers that are easy to refer to, even during interactions with service users. For example, the addition of a checklist related to clinical guidelines for providers, in addition to screening and health education, led to substantial reductions in BP in Bangladesh, Pakistan, and Sri Lanka [19].
While the ongoing investments in monetary incentives for health care providers and mechanisms for facility quality improvement have facilitated increases in the diagnosis of hypertension, our study revealed that there were other barriers to care that prevented case detection. A series of in-depth conversations with stakeholders and reviews of the global literature suggests that these gaps in hypertension diagnosis can be addressed in part by scaling up community screening, mobilizing lower-skilled health care providers and pharmacies, and providing accessible and relevant guides for health workers.
Through the ongoing investment project, there is an entry point to introduce these solutions within the 400 participating PHCs in Sogd and Khatlon Oblasts, to monitor the resulting changes in hypertension detection rates, and to engage iteratively in the above process of diagnosing other gaps in service delivery.

Discussion
The cascade of care framework provided a systematic way of assessing the state of hypertension care within PHC settings in Tajikistan. It confirmed that existing strategies and programs might need to be reinforced with interventions that identify undiagnosed hypertension cases while addressing gaps in other stages of the cascade. The series of indepth discussions with local stakeholders that followed illustrated the multi-level factors that were perceived to influence drop-offs along the cascade of care and provided guidance on the interventions that were best able to target the identified factors. Scoping  were several discussions about wrong beliefs about hypertension and its management in this context, including the fear of potential addiction to hypertension medication, stigma facing young women who were diagnosed with chronic conditions, and the assumption that individuals younger than 40 years did not require screening for hypertension. In reflecting over potential solutions to the service delivery challenges, the "Chaikhana" (tea house) meetings, which are social gathering places specific to the Central Asian context were identified as a means of engaging men in discussions on hypertension and its treatment.
Furthermore, health caravans, which have been used since 2009 for improving health care access in rural and remote areas in Tajikistan, was highlighted as an avenue for closing gaps in screening for hypertension in these localities.