**2. The concept of primary health care**

In Lesotho, PHC is provided at health centres (HCs) and health posts and at community level [2]. Community health workers, also known as village health workers (VHWs), are patients' first formal contacts with the health system. The VHWs are trained community members who help patients in the community and form a link between communities and health centres [7]. Implementers at the health centres can, therefore, play an important role in decreasing the need for higherlevel referral by providing integrated service delivery [8].

Lesotho adopted the Alma-Ata Declaration in 1979 [9]. The Lesotho National Health Policy, which has been used in draft form since 2004 [9], is largely based on the Alma-Ata Declaration on PHC and involves the establishment of 18 health service areas. The District Health Management Teams (DHMTs) are responsible for PHC activities in health centres at a district level. The staffing of health centres (HCs) is determined by whether the facility is rural and small in size or urban and larger in size. Rural HCs are manned by registered nurses while urban ones have registered nurses, doctors, pharmacists and laboratory technologists [9].

Primary health care (PHC) was conceptualised and agreed to be a global solution to the problem of providing comprehensive health services to all at the Alma-Ata Conference in 1978. The conference defined PHC as,

*Use of Primary Healthcare Facilities for Care and Support of Chronic Diseases: Hypertension DOI: http://dx.doi.org/10.5772/intechopen.101431*

*'essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community, through their full participation and a cost that the community and country can afford to maintain, at every stage of their development in the spirit of self-reliance and self-determination' [10].*

Sadly, the implementation of comprehensive service delivery as determined by the Alma-Ata Declaration failed to be consistent and was fragmented based on financial, disease-specific and strategic reasons; therefore service provision of varying degree is continuously offered. However, the integration of essential services and strengthening of health services comprise quantifiable comprehensive service delivery [11, 12].

The low-and-middle income countries, including Lesotho, have selected and serious health problems that are given special attention, and this results in fragmented services. An overwhelming disease burden, donor-driven care and unclear frameworks, guidelines or indicators of PHC are responsible for the prevailing fragmentation of care [11]. The issues of a holistically, patient-centred approach can be met by adopting an integrated service delivery models. The integration of PHC services approach not only embraces the 'best practice' model, and can prevent duplication of services, reduce the risk of adverse events and consequently improve quality of care [11, 13].

The sustainability of health care can be maintained by paying attention to all diseases, not only to prioritised diseases as this creates gaps instead of strengthening the health system [11]. Consequently, the prevalence of preventable illnesses has increased. Conditions, such as hypertension and diabetes, are increasing yearly despite highly specialised care [14]. This results in increasing prevalence of these preventable conditions, patients who receive fragmented service delivery have to visit health centres to receive different specialised services on different days for different, but related, health needs [15]. The consequences of separate, specialised services undermine holistic individualised patient care, patients' adherence to medication, multiple clinic visits, each time enduring long waiting periods, with endless referrals between departments, resulting in high patient 'no-show rates' for appointments [11, 16].

The National Health Sector Strategic Plan 2012–2017 and the Lesotho PHC Revitalisation Plan 2011–2017 show how Lesotho recommitted itself to the original Alma-Ata Declaration for all health centres, including the health centres in Maseru district [7]. Also the Ministry of Health (MoH) undertook several health reforms [7, 8].

It is, however, indicated that lack of formal framework with documented strategies leads to haphazard implementation of integrated primary health care (IPHC), and the Lesotho national policy is also wanting in this regard [8, 17]. It is therefore indicated that when the registered nurses implement IPHC, they based themselves on their own understanding. According to Posholi, to date, PHC has had very few comprehensive implementation frameworks or guidelines [17]. Again, Valentijn et al. stipulate a serious need for standardised, tabulated, systematic procedures for implementation of IPHC [12]. In the absence of standardised protocols across settings, PHC implementation remains subjective and, sometimes, misguided [17, 18]. Even the WHO has cautioned that the absence of standard guidelines for implementation has the potential to derail the initial vision of PHC [19].

It was indicated that the MoH depends on registered nurses to implement IPHC. They are the key personnel who attend to the patients visiting health centres, then referred to a higher level of care, if needed, based on the patient's diagnosis [20]. The registered nurses employed at the health centres report to the registered nurse in charge of the health centre, who in turn report to the relevant DHMT [21].

As initially planned, PHC brings health promotion, disease prevention, cure and care together in a safe, effective and socially acceptable manner to the community [22]. The report by Stender et al. further discusses the skills that are acquired and the training that healthcare workers at the PHC level receive [22]. These included history taking, performing a physical examination and making a nursing diagnosis during a client consultation, problem-solving and decision-making skills especially in the absence of a doctor and completing patient records as well as an appreciating the importance of recordkeeping. Stender et al. point out one of the key elements of PHC which involves bringing health care closer to where people live by conducting home visits and facilitate community involvement in health care through community outreach [22].
