Lessons Learned From Treating 34 Million People With Hypertension: The Global HEARTS Initiative.

Abstract

Hypertension is the leading cause of preventable death globally, yet only approximately 1 in 5 people with hypertension have their blood pressure (BP) controlled, despite availability of effective, generic medicines and the World Health Organization HEARTS technical package of effective, scalable hypertension control interventions. Since 2017, Resolve to Save Lives has collaborated with national governments and other stakeholders to support HEARTS-based hypertension control programs. By December 2024, approximately 34 million people were started on treatment at >220,000 primary care facilities across 38 countries. This paper describes common barriers to and facilitators of success and shares lessons learned from this ongoing multi-country collaboration. Linear drug- and dose-specific treatment protocols are effective, cost saving, and allow nonphysician health care workers to participate in hypertension treatment. Implementing country-developed protocols improves uptake; countries needed to use advocacy and mentoring to shift provider behaviors and policy barriers hindering full implementation. Although treatment can cost <U.S.$5 per patient per year, reliable access to affordable, quality-assured medicines is often a critical bottleneck to program scale-up. Strategies to improve drug supply are context specific and include morbidity-based forecasting and advocacy to increase funding and include protocol medicines in national essential medicines lists. Demand for medicines increases exponentially once programs start, and many resource-constrained countries require additional investments; no likely external funding sources are on the horizon. An effective digital system that provides real-time information to improve patient management and program performance is critical to scale HEARTS programs. User-centered, off-line-first digital information systems, and focus on critical metrics, particularly BP control rate, facilitate steady progress. Team-based care and task shifting face policy and institutional barriers requiring advocacy for enabling policies, competency-based training, structured mentoring, and supervision. Strategies that improve treatment uptake, retention in care, and control include eliminating user fees including for medicines, treatment decentralization, multimonth prescriptions for patients with stable controlled BP, and integration into primary care services. Achieving 50% community BP control is within reach if global organizations and national health programs prioritize implementing the World Health Organization HEARTS program.