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Contribution to the Annual Report 2015 of the MMI Network

Innovating the delivery of hypertension care

Innovating the delivery of hypertension care

Gideon Dapaa, 49, a high school teacher from the Lower Manya Krobo District in the Eastern region of Ghana, was diagnosed with hypertension six years ago. He admits that at the end of a long day at work he prefers to watch TV rather than do exercise. To help patients like Gideon manage their disease, the Novartis Foundation has expanded its work to improve the control of hypertension by making services more accessible in the community while empowering individuals to take more responsibility in the management of their own health.

We are at a crucial point in global health where we see health systems in low- and middle-income countries (LMICs) still overburdened with infectious disease and maternal and child health challenges, and now struggling with the emerging crisis of non-communicable diseases (NCDs), such as hypertension, diabetes, chronic respiratory diseases and cancer. Almost 70% of all deaths globally are associated with NCDs and four out of five of these deaths occur in LMICs. Despite this high burden, only 4.6% of overseas development assistance for health was allocated toward NCDs in 2013.

High blood pressure and hypertension are the leading cause of cardiovascular disease worldwide. More than three quarters of deaths from cardiovascular disease take place in low- and middle-income countries (LMICs); and at 46% the African continent has the highest prevalence of raised blood pressure in the world. The World Health Organization’s most recent estimate of the prevalence of hypertension in Ghana is 27.3%. Yet few control efforts are in place, and as a result only one in twelve people are actively managing their hypertension.

Deaths from hypertension are estimated at 9.4 million people annually globally, which is equivalent to the mortality of all infectious diseases combined. In Ghana, more than a quarter of the adult population has hypertension, but only 4% of these patients have their blood pressure under control.

The Novartis Foundation works with local and global partners to catalyze scalable and sustainable healthcare models to improve access and health outcomes. Previously much of our work focused on infectious disease and maternal and child health issues in rural Africa, while in recent years we now focus on programs that also address NCDs. Among these diseases, the Novartis Foundation chooses to pioneer new health service models to tackle hypertension, as it is the prime risk factor for cardiovascular disease, the number one burden of disease globally.

We work together with diverse partners, from different sectors and disciplines, to build evidence on what works to address this new global health crisis across low- and middle-income countries.

Our first innovative model to address hypertension was launched in 2015 in Ghana: the Community-based Hypertension Improvement Project (ComHIP), a three-year program that brings together partners from the public and private sectors, uses digital technology to connect providers at different levels, and empowers patients to take more responsibility in the management of their own health. The intervention maximizes opportunities for screening, diagnosis and treatment of hypertension, outside the health system, while strengthening existing community-based healthcare services. The model aims to build evidence on the impact of task shifting and involvement of non-traditional health providers in hypertension management, and will assessed the impact on blood pressure control at population level.

Partners of the Novartis Foundation in this ComHIP program are FHI 360, the Ghana Health Services (MOH), the London School of Hygiene & Tropical Medicine Centre for Global NCDs, the School of Public Health at the University of Ghana, VOTO Mobile and many local partners.

Carried out in a district close to an urban center in Ghana, ComHIP shifts the point where patients access healthcare from the hospital, which is often distant and crowded, to the community. Local businesses and healthcare workers based in the community are trained to screen and care for hypertensive patients.

The program has launched with 44 community health nurses from the Ghana Health Service. Each of them makes around 100 home visits a month to patients with various medical needs.

The community health nurses have been provided with blood pressure (BP) measuring equipment and will additionally screen every patient they see for hypertension following the other duties of their visit. Besides the nurses, attendants in 46 local drugstores have been trained to offer a BP screening package to their customers, including a BP measurement and a hypertension information package.

As digital health technology can empower patients in the management of their disease, expand patient reach and make healthcare more efficient, digital health components have been integrated into ComHIP, in collaboration with a Ghanaian technology company VOTO mobile. ComHIP includes e-guidelines for health workers as well as healthy living tips for patients via SMS to reduce risk factors for cardiovascular disease and to support adherence to therapy.

Available in four languages – English, Krobo, Twi and Ewe – the messages are aimed at helping patients adhere to their treatments and keep check-up appointments, while also providing lifestyle tips. For example: “Hello! Remember to take your pills today to control your blood pressure and stay healthy!” and “Avoid adding too much salt to your food. Try replacing salt with some herbs or local spices to enhance the natural flavor. Your food can still taste great!” Messages will also be sent to the community nurses to alert them if their patients are not turning up to their scheduled appointments.

Now, patients like Gideon can better manage their condition through the ComHIP interventions that help patients address their disease with the care of local nurses or staff at a nearby drugstore without the need for time-consuming trips to the nearest hospital.

ComHIP will run until December 2017 and will also include a second district as a comparison site where current hypertension services will be provided without program interventions. The impact is being evaluated by teams at the London School and the University of Ghana, both on health outcomes and the cost-effectiveness.

The results of the project will be used to inform future Ghana Health Service programming and will determine whether a community-based model can be applied in other contexts and low-income settings. The foundation and its partners will share the results with the global health community and also plans to incorporate learnings into our future programs.

The Novartis Foundation’s goals extend beyond Ghana and hypertension; we seek to build evidence on what type of healthcare delivery models and technologies are effective, and then adapt and apply them to help manage the overall dual burden of infectious and non-communicable diseases that low and middle-income countries are facing.

The Novartis Foundation continues to provide platforms to catalyze new thinking, currently leading a dialogue series on the need to urgently address non-communicable diseases. Last year’s edition took place in London to discuss innovation and scale in hypertension management, (, the forthcoming edition will bring experts together on 29 November 2016 in Basel, Switzerland.

Contribution by the Novartis Foundation (member of Medicus Mundi Switzerland) to the Annual Report 2015 of the MMI Network

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