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
Establish administrative structure and survey current resources
| 1A | 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. | GENERAL TOOLS AND TEMPLATES | ||
| 1B | Establish relevant contracts | ||
|---|---|---|---|
| Contracts are created for essential program components such as staffing and workspace. | GENERAL TOOLS AND TEMPLATES There are no tools or templates for this step. Contracts will differ based on vendor type and country. | ||
| 1C | 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. | GENERAL TOOLS AND TEMPLATES | ||
| 1D | 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. | GENERAL TOOLS AND TEMPLATES | ||
| 1E | Budgeting | ||
|---|---|---|---|
| The budget should be comprehensive, including both product and operational elements for program start-up and maintenance. | GENERAL TOOLS AND TEMPLATES In development | COUNTRY-SPECIFIC EXAMPLES In development | |
| 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. | GENERAL TOOLS AND TEMPLATES WHO HEARTS “E” module WHO tool for the development of a consensus protocol for treatment of HTN Simple, practical HTN treatment protocols (Also available in Spanish, Chinese) | COUNTRY-SPECIFIC EXAMPLES Ethiopia Hypertension Prevention and Control project Consensus Planning Meeting Agenda | |
| 2B | Secure stakeholder approval of protocol | ||
|---|---|---|---|
| All relevant stakeholders should approve the protocol. Typically, the Ministry of health will have final approval. | GENERAL TOOLS AND TEMPLATES There are no tools and templates for this step. The approval process may vary by institution or Health Ministry. | ||
| 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. | GENERAL TOOLS AND TEMPLATES Calcium channel blocker initial monotherapy as first line treatment Single pill combination as first-line treatment | COUNTRY-SPECIFIC EXAMPLES Bangladesh Henan, China Ethiopia Kerala, India Madhya Pradesh, India Punjab, India Nigeria Philippines PAHO countries | |
| 3A | Inventory current medications | ||
|---|---|---|---|
| Conduct an inventory survey. The inventory should include medications at the store and facility level. | GENERAL TOOLS AND TEMPLATES
| ||
| 3B | Inventory current blood pressure devices | ||
|---|---|---|---|
| Conduct an inventory survey at the facility level. | GENERAL TOOLS AND TEMPLATES | ||
| 3C | 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. | GENERAL TOOLS AND TEMPLATES | COUNTRY-SPECIFIC EXAMPLES Medication Forecasting Example – Protocol 1 Medication Forecasting Example – Protocol 1b (Single pill combination) Medication Forecasting Example – Protocol 2
| |
| 3D | Forecast blood pressure device needs | ||
|---|---|---|---|
| Program supervisors work with facility-level managers to identify any gaps and project future needs of BP devices. | GENERAL TOOLS AND TEMPLATES Blood pressure device forecasting for opportunistic screening |
| |
| 3E | 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. | GENERAL TOOLS AND TEMPLATES |
| |
| 3F | Procure blood pressure devices | ||
|---|---|---|---|
| Assess the current procurement process for BP devices and consider alternative options as relevant | GENERAL TOOLS AND TEMPLATES How to choose an automated device A 90-second primer on automated digital BP monitors Automated digital BP devices fact sheet WHO technical specifications for automated non-invasive BP measuring devices with cuff Suggested Requirements for External Validation Studies List of validated BP monitors- Stride BP
| COUNTRY-SPECIFIC EXAMPLES Example of a Request for Proposal for blood pressure devices | |
| 3G | Utilize and strengthen supply chains | ||
|---|---|---|---|
| Strengthen supply chain for medicine distribution and establish procedures for monitoring and refilling medication inventory. | GENERAL TOOLS AND TEMPLATES | COUNTRY-SPECIFIC EXAMPLES Drug stock tool – India example Daily medication consumption record
| |
| 4A | Develop training materials | ||
|---|---|---|---|
| When developing materials, consider adapting pre-existing training materials of good quality. | GENERAL TOOLS AND TEMPLATES CDC Hypertension Management Training Curriculum PAHO Course: Management of hypertension for primary care team Training Materials for Simple App
| COUNTRY-SPECIFIC EXAMPLES India Hypertension Control Initiative Training Manual India Hypertension Control Initiative Training Manual (including Simple application) | |
| 4B | 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. | GENERAL TOOLS AND TEMPLATES | COUNTRY-SPECIFIC EXAMPLES India Hypertension Control Initiative training of trainers presentations | |
| 4C | Train health care workers | ||
|---|---|---|---|
| Supervisors facilitate practical training which includes topics such as measuring blood pressure, hypertension management, data collection, data entry and reporting. | GENERAL TOOLS AND TEMPLATES BP measurement checklist | ||
| 4D | Establish process for facility-level monitoring and mentorship | ||
|---|---|---|---|
| Create a standard form recording intervention fidelity and practice supportive supervision. | GENERAL TOOLS AND TEMPLATES
| COUNTRY-SPECIFIC EXAMPLES India Hypertension Control Initiative supportive supervision presentation | |
| 5A | Establish hypertension indicators | ||
|---|---|---|---|
| Establish program indicators based on the HEARTS “S” module indicators. | GENERAL TOOLS AND TEMPLATES | COUNTRY-SPECIFIC EXAMPLES | |
| 5B | 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. | GENERAL TOOLS AND TEMPLATES
India Hypertension Control Initiative non-digital hypertension patient treatment card India Hypertension Control Initiative Simple App digital patient record | ||
| 5C | Establish process for data analysis | ||
|---|---|---|---|
| Establish a method for calculating indicators. Ensure data security and privacy, as well as quality control. | GENERAL TOOLS AND TEMPLATES Simplified Indicator Calculator/Registration Standards to Facilitate Data Sharing and Use of Surveillance Data for Public Health Action | COUNTRY-SPECIFIC EXAMPLES Country X Example: Simplified Indicator Calculator/Registration | |
| 5D | 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 | GENERAL TOOLS AND TEMPLATES | COUNTRY-SPECIFIC EXAMPLES India Hypertension Control Initiative registry, annual & quarterly report (non-digital) | |
| 6A | 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. | |||
| 6B | Manage 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. | GENERAL TOOLS AND TEMPLATES Team-based Hypertension Management in Primary Health Care (RTSL) | COUNTRY-SPECIFIC EXAMPLES Strategies to prevent and reduce patient loss to follow up (India Hypertension Control Initiative | |
| 6C | 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. | COUNTRY-SPECIFIC EXAMPLES Hypertension Control in Integrated HIV and chronic disease clinics in Uganda in the SEARCH study | ||
For supplementary implementation guidance from HEARTS in the Americas, please consult HEARTS in the Americas: Guide and Essentials for Implementation.
Cardiovascular Health
Hypertension Control
Sodium Reduction
