title: Enablers and barriers for implementing high-quality hypertension care in a rural primary care setting in Nigeria: perspectives of primary care staff and health insurance managers.
abstract: BACKGROUND
  Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care.
  
  
  OBJECTIVE
  We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria.
  
  
  METHODS
  Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques.
  
  
  RESULTS
  Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider-insurer relationships; automated administration systems; and tailoring guidelines/patient education.
  
  
  CONCLUSIONS
  By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA.
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.|Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; f.odusola@gmail.com; j.a.haafkens@amc.uva.nl; A.O.Odusola@amc.uva.nl.
authors.forename: Aina O
authors.initials: AO
authors.lastname: Odusola
authors.affiliation: Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Karien
authors.initials: K
authors.lastname: Stronks
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
authors.forename: Marleen E
authors.initials: ME
authors.lastname: Hendriks
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
authors.forename: Constance
authors.initials: C
authors.lastname: Schultsz
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
authors.forename: Tanimola
authors.initials: T
authors.lastname: Akande
authors.affiliation: Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria.
authors.forename: Akin
authors.initials: A
authors.lastname: Osibogun
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Henk
authors.initials: H
authors.lastname: van Weert
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Joke A
authors.initials: JA
authors.lastname: Haafkens
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D001291:Attitude of Health Personnel; D002318:Cardiovascular Diseases / Q000517:prevention & control; D005260:Female; D014943:Global Health; D006282:Health Personnel; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D036301:Qualitative Research; D012307:Risk Factors; D019035:Rural Health Services
keywords: community-based health insurance; hypertension; primary care; qualitative study; stakeholder perspectives; sub-Saharan Africa