UCLA

Worldwide, more people die from cardiovascular diseases (CVDs) than from any other diseases. Of these deaths, 80% are due to heart attacks and strokes, and about three quarters occur in low-and-middle income countries (LMICs). In the Region of the Americas, CVDs result in 1.9 million annual deaths of which one third occur before the age of 70. Hypertension is the underlying cause of 60.1% of all ischemic heart disease and 63.7% of all strokes. The estimated prevalence of hypertension ranges between 20% to 40%. To respond to CVDs, the World Health Organization (WHO) launched the Global Hearts Initiative in 2016 for the prevention and management of CVDs through policy and health system strengthening interventions organized in a set of technical packages. The HEARTS Technical Package is a group of evidence-based interventions: Healthy-lifestyle counseling, Evidence-based treatment protocols, Access to essential medicines and technology, Risk-based management, Team-based care, and Systems for monitoring. The Pan American Health Organization (PAHO) has been guiding the HEARTS implementation in the Americas, and Colombia is part of the first cohort of HEARTS implementing countries.

The main purpose of this study is to analyze the current implementation of the HEARTS Initiative in Colombia, first by describing overall implementation conceptual underpinnings and second, by mapping the current implementation strategies onto the Consolidated Implementation Research Framework (CFIR). The method used is a qualitative inquiry based on semi-structured interviews of 54 implementers in Colombia from the twelve original public primary care health centers that are implementing HEARTS and few referenced national and state level health officials. Inductive analyses of the themes from the interviews allowed for the construction of a program theory of change from the ground up. Deductive analyses that applied the CIRF to the data identified higher order factors that also shaped implementation. The results show high homogeneity in the level of information and absorption of the model across the twelve public primary health centers. The core components proposed by the HEARTS model were adapted to the context of Colombia which was still undergoing a health care reform that started in 2015, which created policies and a health care model into which the HEARTS model was being inserted. HEARTS driven data cleaning processes, development of standardized hypertension treatment protocols and redesigning of patient workflows were important milestones of implementation. Leadership at all levels, human resources stability and continuous training were determining cross-cutting factors that affect the adoption of the HEARTS model. The simplicity of the HEARTS model, the inclusion of front-line practitioners from the onset and the support of the external international organizations have positively affected implementation. Lack of coordination with financing actors, such as insurance entities, may pose one of the greatest challenges to implementation and sustainability. Mapping the implementation of HEARTS in Colombia contributes to the knowledge base on effective implementation of chronic disease management models in LMIC.