National User Guide on the Prevention and Treatment of Hypertension in Adults at the PHC Level 2021

Objectives

The guide supports a long and healthy life for all South Africans by preventing, detecting, treating and controlling hypertension, reducing cardiovascular risk and complications, and limiting impacts on individuals, families, health services and the wider economy.[1][2]It positions hypertension care within broader non-communicable disease prevention, addressing co-morbidities and modifiable risks rather than relying solely on blood-pressure thresholds.[3][4]

• Strengthen accurate blood-pressure measurement, early diagnosis, comprehensive clinical management, sustained control and referral to the appropriate level of care.[1][5]
• Promote health literacy, healthy lifestyles and self-management through physical activity, healthy eating, portion control, reduced salt intake, tobacco cessation, moderate alcohol consumption, stress management and regular medicine-taking.[6][7]
• Screen adults aged 18 years and over attending primary healthcare facilities, particularly people at elevated risk, and use community and household outreach to identify people who may not know that they have hypertension.[2][8][9]
• Assess total cardiovascular risk, clinical status and co-morbidities, including diabetes, kidney disease, previous cardiovascular conditions, pregnancy and human immunodeficiency virus infection.[2][3][10]
• Achieve and maintain blood pressure below 140/90 mmHg through lifestyle modification, patient education, adherence support and stepped clinical treatment.[11][12][13]
• Prevent maternal and perinatal complications through early detection, monitoring, treatment and timely referral for hypertensive disorders in pregnancy.[14][15]
• Address hypertension across the life course, including early recognition in adolescents and cardiovascular risk reduction for people with diabetes, obesity and heart failure risk.[16][17][18]

Implementation

Delivery is centred on people-centred primary healthcare, supported by the District Health System primary healthcare re-engineering model, the Ideal Clinic Realisation and Maintenance Programme, national policies, South African clinical protocols and the World Health Organization HEARTS technical package.[1][19][20]Care combines facility-based screening and management with community health promotion, household outreach, referral networks and patient-centred self-care support.[20][6][9]

• Use calibrated, appropriately sized blood-pressure equipment and standardised measurement procedures, including multiple readings at the first visit and confirmation at separate visits for mild or moderate hypertension.[21][11]
• Undertake routine screening-room assessment for non-emergency facility attendees, including height, weight, body mass index, waist circumference, blood pressure and urine dipstick testing.[9][22]
• Deploy Ward Based Outreach Teams and Community Health Workers to measure blood pressure during household visits, deliver understandable health messages, identify risk factors, link people to facilities, support adherence and bridge formal services with communities.[6][8][9][23]
• Provide health promotion through individual consultations, primary healthcare teams, waiting rooms, schools, group activities, community screening events, the Integrated School Health Programme and non-governmental organisations.[6][8]
• Apply cardiovascular-risk assessment tools using demographic, cholesterol, blood-pressure, smoking and diabetes variables, and reassess people with low risk and no risk factors after five years.[24][25]
• Deliver stepwise treatment that starts with lifestyle modification where clinically appropriate, adds antihypertensive medicines when control is not achieved or risk is higher, and favours fixed-dose combinations where available to improve adherence.[12][13][26]
• Review patients monthly until blood pressure is controlled and every six months thereafter, while monitoring blood pressure, weight or body mass index, renal function, urine protein, blood glucose and potassium according to treatment and clinical risk.[26]
• Use adherence clubs, peer support, pre-packed medicines, collection arrangements, shared decision-making and simplified medicine regimens to reduce barriers to long-term treatment.[27][28][23]
• Coordinate up-referral for specialised or emergency care and down-referral for continued management, rehabilitation or palliative care across clinics, community health centres, hospitals, community services and intersectoral services.[20][29]
• Refer resistant hypertension, target-organ damage, severe adverse drug reactions, hypertensive urgency or emergency, and specified young adults to district hospital services; immediately stabilise and transfer patients with hypertensive emergencies.[26][27][28]
• Provide pregnancy-specific monitoring, treatment and referral, including urgent management of severe pre-eclampsia or eclampsia and structured transfer processes for women with severe features.[30][15][31]
• Strengthen operational accountability by collecting information daily, analysing it quarterly, reviewing facility data in monthly management meetings, and implementing remedial action where performance is inadequate.[32][33]
• Assess service readiness and quality through patient flow, guideline and tool availability, staff training, equipment, laboratory services, medicine availability, record quality, referral arrangements and appointment adherence.[32][33]
• Engage the National Department of Health, provincial health departments, the World Health Organization, clinical experts, professional societies, civil organisations, the National Essential Medicines List Committee and relevant programme directorates in guide development and implementation support.[5]

Monitoring & Evaluation

Monitoring combines routine blood-pressure measurement, cardiovascular-risk assessment, treatment follow-up, clinical safety checks and facility-level review to improve hypertension control. The guide also includes surveillance, monitoring and evaluation as a dedicated component, although it does not provide a single consolidated indicator framework, reporting schedule or national accountability structure.[5][32][33]

• Measure blood pressure for all adults attending primary health-care facilities and through Ward Based Outreach Team household visits, using correct technique, appropriate cuffs, calibrated equipment and repeated readings to confirm diagnosis.[8][9][21][11]
• Calculate and record cardiovascular disease risk using demographic, blood-pressure, cholesterol, smoking and diabetes variables; reassess people with risk below 10% and no risk factors after five years.[24][25]
• Assess whether blood pressure has reached and remains below 140/90 mmHg, with review after three months of lifestyle modification and monthly after treatment escalation until control is achieved.[11][12][13][26]
• Review patients every six months once blood pressure is controlled, while monitoring weight or body mass index at visits and undertaking specified baseline, six-monthly and annual renal, urine-protein, potassium and glucose checks for relevant treatment groups and clinical risks.[26]
• Monitor treatment adherence, missed appointments and retention in care through appointment-register review, patient follow-up and adherence-support mechanisms including clubs and community health worker support.[28][23][33]
• Classify uncontrolled hypertension as blood pressure above 140/90 mmHg in a known hypertensive patient within the preceding six months, regardless of cardiovascular risk-factor status.[33]
• Monitor resistant hypertension by confirming measurement accuracy, adherence, lifestyle adherence and possible white-coat hypertension before referral.[27]
• Undertake frequent clinical monitoring in hypertensive pregnancy, including repeat blood-pressure measurements, proteinuria assessment and weekly maternal and fetal checks for chronic hypertension.[14][30]
• Monitor severe pre-eclampsia or imminent eclampsia through 30-minute blood-pressure and reflex checks, hourly urine output, and 15-minute observations during stabilisation and transfer.[15][31]
• Review facility data daily and analyse it quarterly; require facility managers to consider data at monthly management meetings and implement remedial action where performance is inadequate.[32][33]
• Assess service readiness and quality through patient flow, clinical guidelines, staff training, equipment, laboratory services, medicine availability, records and referral arrangements.[32]

Formal programme-level indicators, routine reporting requirements, surveillance arrangements, evaluation designs and named accountability roles are not specified beyond the clinical, facility-review and corrective-action processes described.[5][32][33]

Costing & Financing

Costing and financing information is very limited. No overall budget, costed implementation plan, budget allocation, financing gap, resource-mobilisation strategy, cost-effectiveness analysis or economic assumption is specified for hypertension prevention, screening, treatment, referral, monitoring or health-promotion activities.[6][13][32]

• Provide equipment, laboratory capacity, essential medicines, staff training, records systems and referral arrangements as operational resources for hypertension-service delivery, but without associated prices or allocations.[32]
• Support adherence through access to medicines, simplified single-pill combinations where available, adherence clubs and medicine-collection arrangements, without specifying financing mechanisms or costs.[26][28][23]
• Recognise that the growing burden of non-communicable diseases increases health-care expenses and affects quality of life, but provide no quantified economic impact or costing methodology.[3]
• Record World Health Organisation South Africa funding for the appointment of a Medical Writer during development of the guide; the amount, currency, funding period and wider funding arrangement are not specified.[5]

The guide specifies clinical medicines, diagnostics and monitoring activities, including antihypertensive treatment, pregnancy care and laboratory checks, but does not provide medicine prices, procurement costs, programme budgets or funding sources for these inputs.[26][14][30]