Tools and Guidance to Facilitate Scaling Up Effective Management of Hypertension

A six-step guide for program managers starting up national or subnational hypertension control programs

Overview: The process of starting a hypertension (HTN) program can be broken down into six steps, and augmented by the set of practical, standardized tools in our hypertension control resource library and the WHO HEARTS technical package that can be adapted to the local program and setting. The six steps and corresponding tools in this guide are aligned with the 2021 WHO Guideline for the pharmacological treatment of hypertension in adults.

(Supplementary implementation guidance from HEARTS in the Americas is available here.)

Select each step to see the accompanying guidance and resources

1AEstablish a Memorandum of Understanding (MOU)
 This MOU (or equivalent agreement) is established between partner organization(s) and government entities that are collaborating on the HTN control program. 
1BEstablish relevant contracts
 Contracts are created for essential program components such as staffing and workspace. 
1CForm a technical working group
 A working group will provide technical decision-making, e.g., selection of program sites and selection of a treatment a protocol. 
1DConduct a needs assessment, survey current resources and care delivery models
 A baseline survey documents existing staff numbers, antihypertensive medications and BP measurement devices at the national level and the program scope of work. 
 The budget should be comprehensive, including both product and operational elements for program start-up and maintenance.
2A Convene a consensus conference to discuss and agree upon a drug and dose specific protocol
Convene the technical working group and any other relevant stakeholders (e.g. Ministry of health officials). Larger countries may opt to establish sub-national conferences and protocols, e.g., provincial-level protocols.
2B Secure stakeholder approval of protocol
All relevant stakeholders should approve the protocol. Typically, the Ministry of health will have final approval.
2C Format and distribute protocol document
The protocol document should have a simple, clear design that lends itself to a poster, job aid or handout. It will be distributed at the facility level for display.
3AInventory current medications
 Conduct an inventory survey. The inventory should include medications at the store and facility level.
3BInventory current blood pressure devices
 Conduct an inventory survey at the facility level. 
3CForecast medication needs

Program supervisors work with facility-level managers to project future needs.

Initial drug supply forecasting should incorporate program growth scenarios. Forecasting should also plan for multi-month refills (six months or longer) for patients with stable, controlled blood pressure.

3DForecast blood pressure device needs
 Program supervisors work with facility-level managers to identify any gaps and project future needs of BP devices.
3EProcure and monitor medications

Assess the current procurement process and consider alternative options as relevant.

Monitor medications on a regular basis and reorder as appropriate.

3FProcure blood pressure devices
 Assess the current procurement process for BP devices and consider alternative options as relevant
3GUtilize and strengthen supply chains
 Strengthen supply chain for medicine distribution and establish procedures for monitoring and refilling medication inventory.
4ADevelop training materials
 When developing materials, consider adapting pre-existing training materials of good quality.
4BTrain program supervisors
 The Training of Trainers program includes individuals such as facility managers and program coordinators, who in turn will train healthcare workers in their facilities. It is recommended to include a review of program goals as a part of the training.
4CTrain health care workers
 Supervisors facilitate practical training which includes topics such as measuring blood pressure, hypertension management, data collection, data entry and reporting.
4DEstablish process for facility-level monitoring and mentorship
 Create a standard form recording intervention fidelity and practice supportive supervision.


5AEstablish hypertension indicators
 Establish program indicators based on the HEARTS “S” module indicators.
5BCreate portable patient hypertension record

The patient card records patient information, cardiovascular health history, hypertension treatment dates, BP measurements and medications.

If information system is digital, include a QR code on the patient card if technology allows.

5CEstablish process for data analysis
 Establish a method for calculating indicators. Ensure data security and privacy, as well as quality control.
5DEstablish process and timeline for reporting
 Prepare reports summarizing indicators, e.g., number of patients enrolled, number of patients treated and proportion with controlled BP
6AOpportunistic screening

Encourage placement of BP devices in highly trafficked areas of healthcare facilities so that all patients receive a BP measurement at registration.

Establish new patient referral linkages from district hospital facilities to local primary care facilities.

6BManage existing hypertension patients

Establish a standardized system for patient follow up during treatment initiation and for patients with stably controlled blood pressure.

Consider implementing a team-based care model, which can alleviate shortages of medical doctors and nurses and allow more decentralized care.

6CCommunity-based screening and management

Identify well-trafficked locations or events in the community where community health care workers can conduct screening.

Establish new patient referral linkages from community to local primary care facilities.

Consider house-to-house screening.

For supplementary implementation guidance from HEARTS in the Americas, please consult HEARTS in the Americas: Guide and Essentials for Implementation.

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