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BJGP Open. 2018 Nov 28;2(4):bjgpopen18X101613. doi: 10.3399/bjgpopen18X101613. eCollection 2018 Dec.

Delivering integrated hypertension care at private health facilities in urban Pakistan: a process evaluation.

Author information

Chief Coordinating Professional, Association for Social Development, Islamabad, Pakistan.
Professor of International Public Health, Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
Project Coordinator, Association for Social Development, Islamabad, Pakistan.
Research Coordinator, Association for Social Development, Islamabad, Pakistan.
Lecturer, Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
Assistant Professor, Humanities and Social Sciences Department, Bahria University, Islamabad, Pakistan.
Provincial Manager, Non-Communicable Disease Control Program, Lahore, Pakistan.
Director, NCD & Mental Health, Directorate General of Health Services, Punjab, Pakistan.



In Pakistan about 18% of all adults are affected by hypertension, and only one in eight of the prevalent cases have their hypertension controlled. As in many other low-middle income countries, a public-private partnership approach is being considered for delivering non-communicable disease care in urban areas.


This process evaluation was undertaken to understand how an integrated care intervention was experienced by the care providers and patients, and to inform modifications before possible scaling.

Design & setting:

The mixed-methods study was conducted as part of a cluster randomised trial on integrated hypertension care at 26 private clinics.


The care practices were assessed by analysing the clinical records of 1138 registered patients with hypertension. Then semi-structured interviews with service providers and patients were used to understand their respective care experiences. A framework approach was applied to analyse and interpret the qualitative data.


District-led objective selection and context-sensitive staff training helped to get the clinics engaged in partnership working. About one-third of patients with hypertension had associated diabetes or renal compromise. The prescription of drugs is influenced by multiple non-clinical considerations of providers and patients. Many doctors allowed the use of home-based remedies as supplements to the prescribed allopathic drugs. Female patients faced more challenges in managing lifestyle changes. The intervention improved adherence to follow-up visits, but patient attrition remained a challenge.


The integrated hypertension care intervention at private clinics is feasible, and leads to improved diagnosis and treatment in low-income country urban setting. The authors recommend continued implementation research and informed scaling of hypertension care at private clinics.


Integrated care package; general practice; hypertension; mixed methods research; primary health care; private clinics

Conflict of interest statement

The authors declare that no competing interests exist.

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