Evaluating a Community Health Worker-Led Hypertension Programme for Stroke Prevention in Rural Eastern Cape: A Policy Analysis

Hypertension is a leading modifiable risk factor for stroke in sub-Saharan Africa, with rural populations facing significant barriers to effective management. Community health worker (CHW) programmes are a key policy consideration for expanding primary care in resource-limited settings such as the Eastern Cape, South Africa. This policy analysis aimed to evaluate the design, implementation, and potential impact of a specific CHW-led hypertension management programme on stroke prevention in a rural Eastern Cape cohort, identifying key policy-relevant strengths and weaknesses. A qualitative policy analysis was conducted using a document review of programme protocols and grey literature, supplemented by semi-structured interviews with programme managers, CHWs, and local health officials. A stakeholder analysis framework was applied. The analysis identified that the programme improved hypertension screening coverage but faced critical challenges in sustaining patient adherence. A key theme was the lack of a formalised referral pathway and medication supply chain, which undermined CHWs' ability to manage complex cases. A substantial proportion of interviewed CHWs reported regular stock-outs of essential antihypertensive medications. While CHW-led programmes hold promise for decentralising hypertension care, their effectiveness in stroke prevention is contingent upon stronger health system integration, particularly reliable medication supply and clear clinical support protocols. Policy should focus on formalising CHW roles within chronic care teams, securing sustainable medication procurement, and implementing digital tools for patient tracking. Investment in routine supervision and continuous training for CHWs is also critical. community health workers, hypertension, stroke prevention, health policy, South Africa, rural health This analysis provides evidence for policymakers on the systemic barriers facing task-shifted chronic disease programmes in rural Africa, highlighting the integration gaps between community-based initiatives and the formal health system.