# Healthcare provider and health system leader perspectives on barriers to hypertension care in Malawi: insights from integrated and non-integrated HIV care settings

## TL;DR

This study identifies common barriers to hypertension care in Malawi, including medication shortages and lack of training, in both integrated HIV-hypertension and non-integrated clinics.

## Contribution

The study provides insights into the challenges of implementing integrated HIV-hypertension care in resource-limited settings.

## Key findings

- Barriers to hypertension care included medication stockouts, lack of equipment, and insufficient provider training.
- Integrated care clinics faced unique challenges like capacity constraints and medication dispensing issues.
- Improving supply chains and training is essential for better hypertension management in low-resource settings.

## Abstract

Malawi has a significant burden of hypertension, including for people with HIV. The World Health Organization recommends integrated HIV-hypertension care, but such integration is not widely implemented in resource-constrained settings.

This study explored barriers to hypertension care in Malawi from the perspectives of healthcare providers and health system leaders.

We conducted a qualitative study of providers and health system leaders across 14 health facilities in Malawi. Interviews explored hypertension services in integrated (HIV and hypertension) and non-integrated clinics to identify barriers to hypertension care and compare barriers by integration status. Interview guides and analysis used the Consolidated Framework for Implementation Research. All transcripts were double coded and thematic analysis was performed.

From April–May 2023, we interviewed 33 individuals (25 providers and 8 health system leaders). Barriers to hypertension care were largely the same in integrated and non-integrated clinics and included stockouts of antihypertensive medications, lack of equipment, lack of provider training, and weak medical record systems. Providers working in integrated care emphasized the benefits of reduced burden for clients and improved quality of care but also reported unique challenges, including capacity constraints (due to the large number of clients) and inability to provide aligned dispensing of antihypertensive medications and ART (due to antihypertensive medication stockouts).

Barriers to integrated HIV and hypertension care in our study largely reflected challenges for hypertension care more broadly. Future efforts should focus on provider training, supply chain strengthening, equipment procurement, and medical record system strengthening to improve outcomes for people with hypertension and hypertension-HIV multimorbidity.

Main findings: Healthcare providers and health system leaders in our study identified major barriers to hypertension care in Malawi, including medication stockouts, lack of equipment, insufficient provider training, and weak medical record systems, with similar challenges in both integrated HIV-hypertension care clinics and non-integrated clinics.Added knowledge: This study highlights the unique implementation challenges of providing hypertension care in resource-limited settings regardless of whether this care is delivered as part of HIV care or general care, emphasizing the need for improved antihypertensive medication supply chain and workforce training and capacity.Global health impact for policy and action: These insights can inform interventions to improve hypertension management in low-resource settings.

Main findings: Healthcare providers and health system leaders in our study identified major barriers to hypertension care in Malawi, including medication stockouts, lack of equipment, insufficient provider training, and weak medical record systems, with similar challenges in both integrated HIV-hypertension care clinics and non-integrated clinics.

Added knowledge: This study highlights the unique implementation challenges of providing hypertension care in resource-limited settings regardless of whether this care is delivered as part of HIV care or general care, emphasizing the need for improved antihypertensive medication supply chain and workforce training and capacity.

Global health impact for policy and action: These insights can inform interventions to improve hypertension management in low-resource settings.