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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 on the Resolve to Save Lives LINKS website 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.

Select each step below to see the accompanying guidance and resources or

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

  1. Establish administrative structure and survey current resources

    1. Establish 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.

    2. Establish relevant contracts

      Contracts are created for essential program components such as staffing and workspace.

    3. Form 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.

    4. Conduct 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.

    5. Budgeting

      The budget should be comprehensive, including both product and operational elements for program start-up and maintenance.

  2. Select a standard hypertension treatment protocol

    1. 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.

    2. Secure stakeholder approval of protocol

      All relevant stakeholders should approve the protocol. Typically, the Ministry of health will have final approval.

    3. 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.

  3. Ensure start up supply of medications and blood pressure (BP) measurement devices

    1. Inventory current medications

      Conduct an inventory survey. The inventory should include medications at the store and facility level.

    2. Inventory current blood pressure devices

      Conduct an inventory survey at the facility level.

    3. Forecast 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.

    4. Forecast blood pressure device needs

      Program supervisors work with facility-level managers to identify any gaps and project future needs of BP devices.

    5. Procure and monitor medications

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

      Monitor medications on a regular basis and reorder as appropriate.

    6. Procure blood pressure devices

    7. Utilize and strengthen supply chains

      Strengthen supply chain for medicine distribution and establish procedures for monitoring and refilling medication inventory.

  4. Train health care workers and activate health system supervisors

    1. Develop training materials

    2. Train 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.

    3. Train health care workers

      Supervisors facilitate practical training which includes topics such as measuring blood pressure, hypertension management, data collection, data entry and reporting.

    4. Establish process for facility-level monitoring and mentorship

      Create a standard form recording intervention fidelity and practice supportive supervision.

  5. Implement an information system for monitoring (digital or paper system)

    1. Establish hypertension indicators

      Establish program indicators based on the HEARTS "S" module indicators.

    2. Create 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.

    3. Establish process for data analysis

    4. Establish process and timeline for reporting

      Prepare reports summarizing indicators, e.g., number of patients enrolled, number of patients treated and proportion with controlled BP

  6. Enroll patients and observe the program in a pilot setting

    1. Opportunistic 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.

    2. Manage existing hypertension patients

    3. Community-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.