Lineamientos Operativos Para La Implementación De La Iniciativa HEARTS En Ecuador

Objectives

The Ecuador HEARTS Initiative provides a mandatory national framework for strengthening cardiovascular disease prevention and control through first-level health-care services. Its overarching aim is to reduce cardiovascular disease incidence and avoidable complications by promoting healthy lifestyles, screening and identifying people at risk, delivering standardised hypertension treatment, assessing cardiovascular risk, ensuring follow-up, and improving access to essential medicines and technologies.[1][2][3][4]

• Promote healthy eating, physical activity, and prevention of harmful tobacco and alcohol use through facility-based and community activities.[5][6][7]
• Screen all adults for blood pressure, including every person attending a health establishment regardless of consultation reason, and provide outreach screening to people aged over 18 years.[8][3][9]
• Identify, enrol, treat and follow up people with hypertension using updated, evidence-based and standardised clinical processes.[1][2]
• Assess cardiovascular risk using Globorisk in people over 40 years without known risk factors and, where indicated, from 20 years in people with premature cardiovascular disease, familial hyperlipidaemia, major risk factors or relevant comorbidities.[4]
• Apply the HEARTS action areas of healthy lifestyles, evidence-based treatment protocols, essential medicines and technology, cardiovascular-risk management, multidisciplinary teamwork, and monitoring systems.[2]
• Deliver at least one indoor and one outdoor or virtual health-promotion activity monthly in each establishment on physical activity, healthy eating, and prevention of tobacco and alcohol consumption.[6]

Implementation

Implementation is progressively integrated into existing services, with emphasis on primary health care and coordinated action across facility, district, zonal and national levels.[10][11][12]The guidance applies obligatorily in all Ministry of Public Health first-level health-care establishments, supported by the Ministry, the Pan American Health Organization, academia, scientific societies, local actors and communities.[2][8][10]

• Establish zonal management committees and district or technical-office implementation committees, with representation for service provision, health promotion, prevention and control, governance, communication, network coordination and information functions.[11][12]
• Appoint a doctor or health professional at each facility to lead HEARTS implementation and coordinate a multidisciplinary team that may include general or family doctors, nurses, psychologists, pharmacists, nutritionists, social workers, community health technicians, and administrative or statistical staff.[5][4]
• Train zonal, district, facility and newly appointed staff on the operational guidance and HEARTS components, including physical-activity prescription and lifestyle counselling for people with hypertension.[11][12][5][13]
• Deliver intra-mural and extra-mural health-promotion activities using the Ask, Advise, Assess, Assist and Arrange methodology, adapting face-to-face or virtual delivery to local context and applicable emergency provisions.[6][13]
• Engage hypertension clubs, social organisations, community groups, workplaces, local media, health fairs and community events to disseminate healthy-lifestyle messages and support alcohol-risk reduction and smoking cessation.[14][13][7]
• Measure blood pressure through trained personnel using recommended procedures and validated sphygmomanometers, classify readings under the hypertension clinical guideline, and assess abdominal circumference where hypertension is suspected or confirmed.[15][9]
• Apply the specified stepped pharmacological protocol for newly diagnosed hypertension, verify adherence before specialist referral, and exclude pregnant women, people under 15 or over 80 years, and specified clinical groups from this protocol.[9][16]
• Coordinate referral and counter-referral for people with cardiovascular risk factors, target-organ damage or complications, with specialist assessment and return to primary care once stabilised or referral issues are resolved.[17][4]
• Record screening, counselling and hypertension-care information in the Health Care Registration Platform, known as PRAS, including non-pharmacological treatment and relevant diagnostic coding.[6][15][16]
• Monitor implementation quarterly through facility, district and zonal reporting; consolidate annual plans and activity reports; provide facility feedback; and develop short-term improvement plans based on joint analysis.[11][12][5]
• Maintain and analyse HEARTS indicators on blood-pressure control, medicine availability, treatment eligibility and counselling, hypertension register coverage, and screening, including comparisons before and after implementation.[18][19]
• Expand implementation after national pre-implementation in late 2019, beginning in 14 districts in 2020 and increasing coverage by at least 15% of districts annually through 2025.[10]

Monitoring & Evaluation

A monitoring and evaluation system supports implementation of the Ecuador HEARTS Initiative through routine recording, quarterly reporting, indicator analysis, patient follow-up and feedback across health-facility, district, zonal and national levels.[20][11][12][5][18]The framework uses the Health Care Service Registration Platform (PRAS) to document screening and care, while comparing hypertension-control outcomes before and after HEARTS implementation.[15][16][18][19]

• Record blood-pressure screening results, hypertension care, non-pharmacological counselling, waist measurements and other relevant patient-care information in PRAS.[6][15][16][18][21]
• Measure blood pressure for every adult attending a consultation and classify results under the applicable hypertension clinical-practice guideline.[9]Record essential primary hypertension as International Classification of Diseases, 10th Revision, code 110X, while coding concomitant conditions separately.[16]
• Consolidate and verify information on people with hypertension, transmitting it to the relevant HEARTS focal point at the next level of the health system.[12][5]
• Submit facility quarterly reports to the district or technical office within the first five days of the relevant month, and require district bodies to consolidate facility information, annual plans and quarterly reports.[12][5]
• Submit zonal quarterly implementation reports to the national level within the first 15 days of the relevant month, following consolidation of district and technical-office information.[11]
• Monitor implementation quarterly at zonal and district levels across the HEARTS modules, including healthy lifestyles, screening, treatment, cardiovascular-risk management and multidisciplinary care.[11][12]
• Maintain updated HEARTS indicator data at zonal, district, technical-office and health-facility levels.[18]Monitor blood-pressure control among treated people with hypertension over six months, control among programme participants, essential medicine availability for cardiovascular disease and diabetes, eligibility for pharmacological treatment and counselling, population hypertension control, hypertensive-register coverage, and blood-pressure screening.[18]
• Analyse indicators at facility level and report progress, critical bottlenecks and other implementation activities quarterly to the district, with zonal coordination offices consolidating and submitting information centrally.[18]
• Compare PRAS data from before and after HEARTS implementation, including the proportion of people with blood pressure below 140/90 mmHg and progress in coverage of the controlled population.[19]
• Use cardiovascular-risk assessment and clinical classification to determine follow-up requirements, referral decisions and the appropriate level of care.[17][21]
• Provide feedback to health facilities, jointly analyse results and develop short-term improvement plans.[12]
• Track the delivery requirement for each establishment to undertake at least one indoor and one outdoor or virtual health-promotion activity each month, covering physical activity, healthy eating and prevention of tobacco and alcohol consumption.[6]
• Monitor use of the dietary graphic and its 11 messages during health education and communication activities, and verify smoke-free spaces using a checklist.[7]

The available material identifies recording procedures, reporting routes and several operational indicators, but does not provide full indicator definitions, numerical targets, data-quality methods, independent evaluation arrangements, formal surveillance outputs, or sanctions and other explicit accountability mechanisms.[20][11][7][18]

Costing & Financing

No explicit costing, budget allocation, financing source, resource-mobilisation plan, funding gap, economic assumption or monetary valuation is provided for implementation of the HEARTS Initiative.[1][2][4][18][22][23]

• Provide centrally supplied implementation and communication resources, including presentations, briefing materials, checklists, guidance and adapted message resources, although their costs and funding arrangements are not specified.[7]
• Use existing Ministry of Public Health first-level healthcare establishments and health personnel as the mandatory delivery platform, but the resource requirements for staffing, training, medicines, validated sphygmomanometers, PRAS reporting and outreach activities are not quantified.[2][3][15][9]
• Expand implementation from national pre-implementation in September to December 2019, beginning with 14 districts in 2020 and increasing coverage by at least 15% of all districts annually through 2025; associated financial requirements are not specified.[10]
• Coordinate implementation with the Pan American Health Organization, academia, scientific societies and local actors, but the document does not identify financial commitments or in-kind contributions from these partners.[2][8][10]