Addressing the gaps in hypertension care and control in Cuba and Colombia

Despite the availability of cost-effective tools for detection and treatment, uncontrolled hypertension remains the main modifiable risk factor for all-cause mortality, also in low- and middle-income countries, where 75% of all cardiovascular deaths occur. In Latin America and the Caribbean, hypertension affects up to 40% of adults, leading to 1.8 million deaths annually due to cardiovascular diseases.

Our work focuses on ameliorating hypertension management in the primary care setting in Cuba and Colombia. Formative research estimated the prevalence of uncontrolled hypertension and the magnitude of gaps in the care cascade. Subsequently, we designed and implemented a multi-component intervention to improve hypertension control.

We documented a resemblance in control outcomes in the studies conducted in low-middle income urban environments in both countries, despite markedly different health system designs and healthcare models. Yet, a closer examination reveals significant disparities at different stages of the hypertension care continuum. In urban Colombia, we identified a substantial diagnostic gap (35% of hypertensive individuals were undiagnosed) as well as moderate but pervasive out-of-pocket expenditure for hypertension care (on average USD 148 per year). This could be attributed to the fragmented structure of the healthcare system. In contrast, our findings in the Cuban study sites indicated that the hypertension treatment gap is low (93% of patients were prescribed antihypertensive drugs), but patient adherence is compromised (39% were not fully compliant). It seems that the primary healthcare infrastructure in Cuba, while very accessible, is challenged to ensure proper patient follow-up and treatment adherence.

With the participation of community and institutional stakeholders, we designed and implemented a controlled multi-component intervention to address the identified care gaps. It targeted family practices and hypertensive patients under their care and included healthcare delivery redesign, clinical and managerial staff training, and patient communication and engagement components. One year after start-up, the proportion of patients with controlled hypertension in family practices in the intervention arm of the study had more than doubled in comparison to practices in the usual-proceedings arm.

Taking inspiration from the World Health Organization’s Hearts Initiative, we demonstrated that it is feasible to substantially improve hypertension outcomes in low- and middle-income settings that have already achieved a relatively high control rate. While adopting a health systems perspective, the emphasis must be on interventions tailored to the local primary healthcare level, linked with the concomitant development of equitable national public policy. Besides, providing comprehensive financial protection for underserved population groups should curb overall out-of-pocket expenses for chronic care.