Improving cardiovascular health from the local community to the national level with a participative approach

The STEPS survey, undertaken in 2018, showed that cardiovascular disease (CVD) represents the main cause of mortality in Ecuador 1. This survey was planned and carried out by the Ministry of Public Health (MoPH) and the National Institute of Statistics and Census (INEC) with the technical cooperation of PAHO/WHO Ecuador, in order to contribute to the surveillance of noncommunicable diseases (NCDs) and their risk factors. The STEPS survey showed that 19.8% of the population had hypertension. Of these, at least 17% had uncontrolled hypertension and 56.3% did not take any medication for high blood pressure. With this alarming reality, and following advocacy from PAHO/WHO Ecuador, the MoPH made implementation of the HEARTS initiative a priority in 2019 – tackling the prevention and control of arterial hypertension to reduce CVD. In cooperation with the MoPH, PAHO/WHO Ecuador led training sessions with health care workers and procured appropriate equipment. By 2022, according to MoPH data, 130 591 patients were recruited through the HEARTS programme, of whom 75% are now controlled.

How did Ecuador, with the support of the PAHO/WHO Secretariat, achieve this?

The STEPS survey conducted in 2018 was a real turning point: it showed that 50.1% of people between the ages of 18 and 69 had never had their blood glucose measured. It also determined that 37.9% were overweight while 25.7% suffered from obesity. Based on the blood pressure data obtained, it was found that 45.2% of subjects had raised blood pressure which had not been previously diagnosed, 12.6% raised blood pressure which had been diagnosed but not treated, 16.2% raised blood pressure which had been diagnosed and treated but was uncontrolled, and 26.0% raised blood pressure which had been diagnosed, treated and controlled.

In view of the alarming results of the STEPS survey, the MoPH formed a management group dedicated to implementing HEARTS in October 2019. Ecuador Country Office advised the MoPH during the process of pre-implementation and implementation of the HEARTS initiative. Support was provided during the pre-implementation phase to develop an action plan based on a situation analysis and set up different management groups.

Once the members of the management group in charge of implementation and evaluation were identified, PAHO/WHO Ecuador facilitated the workshops with advisers from the regional office and Chile, as well as from the University of Calgary, whose task was to train members of the committee on the various components of the HEARTS initiative and its technical package. The latter comprises six modules: healthylifestyle counselling, evidence-based protocols, access to essential medicines and technology, risk-based CVD management, team-based care and monitoring systems. Training also included standardization of pharmacological and nonpharmacological interventions. PAHO/WHO Ecuador advised the MoPH on development of the communication materials which were used during training. Subsequently, with support from PAHO/ WHO Ecuador and funding from the global public health initiative Resolve to Save Lives, the MoPH rolled out training across 184 first-level health care facilities nationwide, out of a total of 1940. These facilities were located in districts and zones with the highest prevalence of high blood pressure.

Once training was completed, a dedicated station was set up in the 184 health care facilities for measuring the blood pressure of all patients and visitors aged 18 and above. Clear clinical criteria, presented and agreed during training, were used to refer patients to specialists at higher-level health care facilities. PAHO/WHO Ecuador supported these screening activities by procuring blood pressure measuring equipment for all health care facilities and arranging supportive supervision to monitor data collection and referral numbers. A supportive supervision approach was adopted in collaboration with the local health committees which also encouraged people not to miss their referral appointments. If high blood pressure or CVD was diagnosed, health care workers followed predefined pharmacological and nonpharmacological protocols, which included regular visits to patients every three months, delivery of medicines, and counselling on healthy eating and physical activity.

I suffered from grade 2 obesity and was about to have diabetes. My blood pressure was altered. They helped me with consultations and nutritional diets to improve my health and even change lifestyle habits. Now I keep a healthy lifestyle, which I share with my family. I have lost weight, am no longer obese and my blood pressure is stable. The monitoring by the health personnel, and medication and counseling provided have been important to improve my health.” - Sandra Bautista, beneficiary of HEARTS programme

As a result of these actions and positive feedback from the communities, the HEARTS initiative was included within the Ten-Year Health Plan 2022–2031, thus promoting the initiative as a health policy. The cooperation and technical advice from PAHO/WHO Ecuador were critical to the development of this plan, which has transformed the vision of health in the country.

With more than 45 000 Ecuadorian health care workers being trained on HEARTS implementation through the PAHO Virtual Campus, the initiative has been successfully expanded and implemented in 483 health facilities nationwide. Accordingly, in 2022, the World Hypertension League bestowed on Ecuador – from among all the countries implementing the HEARTS initiative – its Award for Organizational Excellence in Prevention and Control of Arterial Hypertension.

An expansion plan for the HEARTS initiative continues with the support of PAHO/WHO Ecuador through health team training, donation of medical supplies and education and communicationmaterials for health care professionals. Ecuador’s goal is that, by 2025, 100% of firstlevel establishments in the country will be implementing this strategy.

The approach of public health workers teams to the community has made it possible to identify, diagnose and offer the appropriate treatment to patients. PAHO/WHO, as the country’s main ally in the field of public health, supports Ecuador in the implementation and expansion of HEARTS and commits its technical assistance to all programmes that face the challenge of cardiovascular diseases, which continue to be the main cause of death in the region.” - Óscar M. Barreneche, PAHO/WHO Representative in Ecuador

Knowledge

WHO country stories: delivering for all

“This impact story was published as part of the WHO country stories: delivering for all report, which presents a snapshot of how WHO has delivered on its mission in countries and contributed to health outcomes across a wide range of issues during 2022-2023.”