Lineamientos Operativos Para La Implementación De La Iniciativa HEARTS En Ecuador

Objectives

Ecuador’s adoption of the HEARTS Initiative seeks to strengthen prevention and control of cardiovascular disease, with an initial focus on hypertension and secondary prevention, through improved primary health care. It aims to reduce cardiovascular disease incidence and avoidable complications by integrating health promotion, screening, diagnosis, treatment and follow-up into first-level health-care services.[1][2][3]

• Promote healthy habits at individual, family and community levels, including healthier diets, regular physical activity, and prevention of harmful tobacco and alcohol use.[3][4][5]
• Offer blood-pressure screening to all people aged over 18 through health facilities and outreach activities, and strengthen early identification of cardiovascular risk.[3][6]
• Standardise the search, identification, treatment and follow-up of people with arterial hypertension, including use of an evidence-based pharmacological treatment protocol in first-level care.[1][3]
• Manage hypertension alongside relevant comorbidities, including diabetes, coronary disease, acute myocardial infarction and renal disease, through integrated care and appropriate specialist support.[7][8]
• Implement the HEARTS components on healthy lifestyles, evidence-based treatment protocols, access to essential medicines and technologies, cardiovascular-risk management, multidisciplinary teamwork, and monitoring systems.[2]
• Apply the guidance mandatorily in all first-level health-care establishments of Ecuador’s Ministry of Public Health.[2][3]

The initiative is intended to be progressively integrated into existing services and to involve health professionals, local actors and communities in prevention and control of cardiovascular disease.[9]Its operational scope includes healthy-lifestyle activities, screening and follow-up pathways, cardiovascular-risk assessment, referral and counter-referral, health-service recording, and monitoring and evaluation.[2]

Implementation

Implementation combines strengthened primary care, community empowerment and coordinated multidisciplinary delivery. A 2018 pilot in the 17D03 Calacalí-Cotocollao and 17D08 Conocoto-La Merced districts of Zone 9 informed national roll-out, which began with pre-implementation from September to December 2019; implementation involved 14 districts in 2020 and was planned to expand by at least 15% of districts annually through 2025.[9]

• Establish a zonal management team in zonal coordination offices, a district or technical-office implementation team, and an operational leader at every health establishment. District teams include representatives for service provision, prevention and control, health promotion, governance, network coordination, communications and statistics.[9]
• Designate a doctor or other health professional to lead a multidisciplinary facility team, drawing on medical, nursing, psychological, pharmaceutical, nutritional, social-work, community-health and administrative staff according to local availability.[4][10]
• Coordinate patient identification, clinical care, follow-up, medicine access and replenishment, treatment adjustment, appointment scheduling, reminders, blood-pressure measurement and healthy-lifestyle counselling through the multidisciplinary team.[11]
• Train health personnel and deliver HEARTS modules through facility-based and outreach activities, recording and reporting completed activities.[12][4]
• Conduct at least one monthly health-promotion activity per establishment for physical activity, healthy eating, alcohol-use prevention and tobacco-use prevention, adapting face-to-face or virtual delivery to local circumstances.[13]
• Work with hypertension clubs, social organisations, public and private institutions, non-governmental organisations, workplaces, media and community groups, while coordinating mass activities with applicable national and cantonal Emergency Operations Committee provisions during the COVID-19 pandemic.[5][14][15]

Service delivery requires all facility staff to offer blood-pressure measurement in facilities and communities, with trained personnel using validated equipment and the relevant clinical procedure. Results are recorded in the Blood Pressure Screening module of the Platform for Health Care Records, known as PRAS, and on the screening card; repeated elevated readings trigger further assessment.[6]People with high-normal readings receive cardiovascular-risk information and undertake consecutive measurements over seven days, with general medical care arranged within five days where at least three readings are elevated.[6]

Clinical consultations identify cardiovascular risk factors, measure abdominal circumference for people with presumptive or confirmed hypertension, arrange indicated tests, and provide advice on diet, physical activity, alcohol and tobacco.[6][7]The first-line hypertension protocol applies to newly diagnosed patients, while treatment may be adjusted and patients referred to specialists or higher-complexity care when blood pressure remains uncontrolled.[7][8]The protocol excludes pregnancy, people younger than 15 or older than 80, severe hepatic insufficiency and adverse drug reactions.[7]

Referral arrangements use the National Health System technical standard for referral, counter-referral, reverse referral and transfer. Patients with cardiovascular risk factors, target-organ damage or persistent hypertension despite treatment may be referred for internal medicine, nephrology or cardiology assessment and returned to first-level care once stabilised or once referral findings are addressed.[16]Cardiovascular risk is assessed for patients over 40 without known risk factors and, where indicated, for people aged 20 to 40 with premature family cardiovascular disease, familial hyperlipidaemia, major risk factors or relevant comorbidities; the Globorisk tool is recommended for national risk assessment.[10]

Governance is led by the Ministry of Public Health, with technical collaboration from the Pan American Health Organization, academia and scientific societies.[2][17]The Ministry’s national subsecretariats and directorates provided approval, validation and technical input across primary care, health promotion, prevention and control, nutrition, mental health, regulatory implementation and non-communicable diseases.[18]

Monitoring operates through quarterly review at zonal and district levels, with facilities analysing HEARTS indicators and reporting progress, bottlenecks and activities to districts; zonal bodies consolidate district information for central submission.[12][11]Indicators cover blood-pressure control among treated and enrolled patients, availability of essential cardiovascular disease and diabetes medicines, eligibility for pharmacological treatment and counselling, population hypertension control, hypertension-register coverage and blood-pressure screening.[11][19]Care records in PRAS support comparison of hypertension control before and after HEARTS implementation, including the proportion of people with blood pressure below 140/90.[19]

Monitoring & Evaluation

Monitoring and evaluation combine routine clinical recording, quarterly implementation reporting, indicator review and service-level improvement actions across the HEARTS Initiative. Health establishments, district and zonal teams maintain and consolidate information for submission to the central level, while the available extracts do not provide indicator targets, baselines, formal evaluation findings or a comprehensive accountability framework.[12][11][19]

• Record blood-pressure screening in the Blood Pressure Screening module of the Plataforma de Registro de Atención en Salud (PRAS) and on the screening card, classify readings under the national hypertension guidance, and arrange additional assessment where repeated elevated readings are identified.[6]
• Apply a seven-day sequence of blood-pressure measurements for people with high-normal readings and arrange medical assessment within no more than five days where at least three of seven readings are elevated.[6]
• Record hypertension and cardiovascular-disease care in PRAS, using International Classification of Diseases, tenth revision (ICD-10) code I10X for essential primary hypertension and separate codes for concomitant conditions.[8][16]
• Monitor blood-pressure control among treated patients over six months and among people enrolled in the programme, alongside population hypertension control, hypertension-register coverage, screening activity, eligibility for pharmacological treatment and counselling, and availability of essential cardiovascular disease and diabetes medicines.[11][19]
• Use PRAS care records to compare hypertension control before and after HEARTS implementation, including the proportion of patients with blood pressure below 140/90 and progress in controlled-hypertension coverage.[19]
• Keep HEARTS indicator data current through zonal, district, technical-office and health-establishment management teams.[11]
• Report quarterly on HEARTS implementation at zonal and district levels, including module activities and improvement actions.[12]
• Submit annual health-promotion plans within the first five days of the relevant period and quarterly activity reports within the first five days of the corresponding month.[4]
• Consolidate annual planning and quarterly implementation reports at district level, then submit zonally consolidated quarterly information to the national level within the first fifteen days of the corresponding month.[12]
• Analyse facility indicators and report quarterly to districts on progress, critical bottlenecks and other activities; zonal coordination bodies consolidate district information for central submission using the attached format.[11]
• Provide feedback to health establishments, review achievements jointly and develop short-term improvement plans.[4]
• Consolidate and verify information on patients with hypertension through the relevant administrative levels.[4]
• Report non-pharmacological counselling for patients with essential hypertension in the Primary Care Recording System using the prescribed categories and groups.[13]
• Monitor use of the Ecuador Food-Based Dietary Guidelines graphic and its 11 messages in edu-communication activities, and use verification checklists supporting institutional declarations of 100% tobacco-smoke-free spaces.[15]
• Apply selective screening for risky alcohol use among adolescents and vulnerable populations with CAGE-AID and AUDIT, enabling timely detection and referral under the adolescent supervision guidance.[15]
• Refer people with cardiovascular risk factors, target-organ damage or persistent uncontrolled blood pressure to higher-level services, and return them to first-level care when blood pressure is stabilised or referral observations are resolved.[16]

The extracts refer to basic indicators, monitoring procedures, progress reports and a separate monitoring and evaluation framework for hypertension-control programmes, but do not specify indicator definitions, target values, reporting completeness standards, independent evaluation methods, surveillance architecture, sanctions or other formal accountability arrangements.[20][11][19]

Costing & Financing

No costs, budget allocations, expenditure figures, financing sources, resource-mobilisation mechanisms, funding gaps or economic assumptions are specified in the supplied extracts.[1][12][6][19][18]

• Provide educational and presentation materials centrally for health-promotion delivery, including materials related to healthy habits and dietary guidance, but no monetary value, procurement budget or funding source is provided.[14][15]
• Require service-delivery inputs such as trained personnel, validated blood-pressure equipment, essential medicines, technologies, multidisciplinary teams and specialist referral pathways, but do not quantify associated resource needs or financing arrangements.[6][7][10][11]
• Expand implementation from a 2019 pre-implementation phase through districts in 2020 and planned annual expansion through 2025, but do not provide a costed implementation plan or identify funding for this expansion.[9]

Accordingly, the supplied material does not permit assessment of affordability, budget adequacy, unit costs, financial sustainability, funding shortfalls or the economic implications of the HEARTS implementation model.[3][16][21]