ABSTRACT

Despite effort in Latin America to implement the HEARTS initiative, hypertension control is still inadequate. There are many advances in the medical and technical arena, but little to promote political and systemic change. The vibrant civil society that has advanced policy change in tobacco control, food policy, and other public health initiatives can make a crucial contribution to prioritize hypertension control in the political agenda, ensure sustainable funding, promote the procurement of affordable and effective medications, and expand community demand for action. The recommended first step for civil society’s involvement is to analyze the political landscape to design an advocacy plan. The political landscape includes a legal analysis, policy mapping, stakeholders mapping, identifying obstacles, mapping community strategies, and risk assessment. The second step is to define policy goals and an advocacy strategy. Based on experience, there would be two main policy goals: to increase political will to make hypertension a top priority, securing necessary resources; and strengthen community awareness and social demand for action. The third step is to develop and implement the advocacy plan with the tools familiar to civil society, including building a case for support, advocacy towards decision makers, media advocacy, coalition building, countering the opposition, and civil society monitoring and accountability. To jumpstart this approach, there should be incentives for civil society and a transition for transferring competencies to a new arena. The results would be more sustainable and scalable hypertension control, better health outcomes, and advances toward the 2030 Sustainable Development Goals and universal health coverage.

Keywords
Hypertension; civil society; policy; Latin America

RESUMEN

A pesar de los esfuerzos para poner en marcha la iniciativa HEARTS en América Latina, el control de la hipertensión sigue siendo inadecuado. Ha habido muchos avances en el ámbito médico y técnico, pero poco ha logrado hacerse para promover el cambio político y sistémico. La vibrante sociedad civil que ha logrado avances en el cambio de políticas sobre el control del tabaco, las políticas relacionadas con los alimentos y otras iniciativas de salud pública puede realizar una contribución crucial para que se dé prioridad al control de la hipertensión en la agenda política, se garantice la financiación sostenible, se promueva la compra de medicamentos asequibles y efectivos, y se amplíe la demanda de medidas por parte de la comunidad.

El primer paso recomendado para lograr la participación de la sociedad civil es analizar el panorama político para diseñar un plan para abogar por la causa. El panorama político incluye el análisis legal, el mapeo de políticas y de las partes interesadas, la definición de los obstáculos y las estrategias comunitarias, y la evaluación de riesgos. El segundo paso es definir los objetivos de las políticas y diseñar una estrategia para abogar por la causa. Con base en la experiencia, las políticas tendrían dos objetivos principales: lograr una mayor voluntad política para convertir la hipertensión en una prioridad absoluta, asegurando los recursos necesarios, y fortalecer la concientización de la comunidad y la demanda de acción por parte de la sociedad. El tercer paso es elaborar y ejecutar un plan para abogar por la causa con herramientas familiares para la sociedad civil, lo que incluye buscar argumentos para lograr el apoyo, abogar ante los responsables de tomar decisiones y los medios de comunicación, crear coaliciones, contrarrestar la oposición, dar seguimiento a la sociedad civil y establecer mecanismos de rendición de cuentas de la sociedad civil.

Para impulsar este enfoque, debería haber incentivos para la sociedad civil y una transición para la transferencia de competencias en un nuevo escenario. Los resultados serían un control de la hipertensión más sostenible y ampliable, mejores resultados de salud y avances hacia los Objetivos de Desarrollo Sostenible de la Agenda 2030 y la cobertura universal de salud.

Palabras clave
Hipertensión; sociedad civil; políticas; América Latina

RESUMO

Apesar dos esforços feitos na América Latina para implementar a iniciativa HEARTS, o controle da hipertensão arterial continua sendo inadequado. Houve muitos avanços na área médica e técnica, mas pouco no sentido de promover mudanças políticas e sistêmicas. A sociedade civil vibrante que impulsionou mudanças nas políticas de controle do tabaco, na política de alimentação e em outras iniciativas de saúde pública pode fazer uma contribuição fundamental no sentido de priorizar o controle da hipertensão na agenda política, garantir financiamento sustentável, promover a aquisição de medicamentos eficazes a preços acessíveis e aumentar a demanda da comunidade por ações.

Recomenda-se que o primeiro passo para envolver a sociedade civil seja uma análise do cenário político para elaborar um plano de promoção da causa. O cenário político inclui análise jurídica, mapeamento de políticas, mapeamento de interessados diretos, identificação de obstáculos, mapeamento de estratégias comunitárias e avaliação de riscos. O segundo passo é definir metas para as políticas e uma estratégia de promoção da causa. Com base em experiências anteriores, as políticas teriam duas metas principais: aumentar o compromisso político de dar prioridade máxima à hipertensão, assegurando os recursos necessários, e fortalecer a conscientização da comunidade e a demanda social por ações. O terceiro passo é desenvolver e implementar o plano de promoção da causa utilizando ferramentas já familiares para a sociedade civil, como a elaboração de argumentos para obter apoio, a defesa da causa junto a tomadores de decisão, a promoção nos meios de comunicação, a formação de coalizões, o combate a oponentes e o monitoramento e responsabilização da sociedade civil.

Para alavancar essa abordagem, deve haver incentivos para a sociedade civil, com uma transição para a transferência de competências para uma nova área. Os resultados seriam um controle mais sustentável e expansível da hipertensão, melhores resultados de saúde e avanços em direção aos Objetivos de Desenvolvimento Sustentável 2030 e à cobertura universal de saúde.

Palavras-chave
Hipertensão; sociedade civil; políticas; América Latina

Hypertension affects between 20-40% of the adult population of the Americas, around 250 million people, and is a major factor in morbidity and mortality from cardiovascular diseases (CVD) (¹1. NCD Risk Factor Collaboration (NCD-RISC). Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet. 2021;398(10304):957-980. doi: 10.1016/S0140-6736(21)01330-1.
https://doi.org/10.1016/S0140-6736(21)01... ). Hypertension is preventable to a significant extent with population level interventions, such as by reducing salt intake and eliminating trans fats from the diet; consuming a diet rich in fruits and vegetables; reducing consumption of alcohol and tobacco; increasing physical activity; and maintaining a healthy body weight. Individual strategies such as scaling up pharmacological treatment to recommended guidelines, facilitating access to essential medicines, and improving primary care services (human resources, infrastructure) are critical in reducing the burden of hypertension.

There have been significant efforts and progress made in this region to reduce the prevalence of hypertension, principally through the Pan American Health Organization’s (PAHO) coordination of HEARTS, a package of best practices, which has been implemented in selected countries working with Ministries of Health (²2. Pan American Health Organization. HEARTS in the Americas. Washington D.C: PAHO; 2022. Accessed on July 20, 2022. Available from: https://www.paho.org/en/hearts-americas
https://www.paho.org/en/hearts-americas... , ³3. Campbell NRC, Ordunez P, Giraldo G, Rodriguez Morales YA, Lombardi C, Khan T, et al.. WHO HEARTS: A Global Program to Reduce Cardiovascular Disease Burden: Experience Implementing in the Americas and Opportunities in Canada. Can J Cardiol. 2021;37(5):744-755. doi: 10.1016/j.cjca.2020.12.004.
https://doi.org/10.1016/j.cjca.2020.12.0... ). The work in our region has focused on reducing the many barriers and promoting facilitators of hypertension control, considering both the demand and supply sides of the problem (⁴4. Jeemon P, Séverin T, Amodeo C, Balabanova D, Campbell NRC, Gaita D et al. World Heart Federation Roadmap for Hypertension – A 2021 Update. Global Heart. 2021;16(1):63. doi: 10.5334/gh.1066.
https://doi.org/10.5334/gh.1066... , ⁵5. Giraldo GP, Joseph KT, Angell SY, Campbell NRC, Connell K, DiPette DJ, et al. Mapping stages, barriers, and facilitators to the implementation of HEARTS in the Americas initiative in 12 countries: A qualitative study. J Clin Hypertension (Greenwich). 2021;23(4):755-765. doi: 10.1111/jch.14157.
https://doi.org/10.1111/jch.14157... ). These efforts aim toward the achievement of the Sustainable Development Goals 2030 of reducing the prevalence of non-communicable diseases (NCDs) by 30%. Key actors in this work have been leaders in the healthcare field, including ministries of health, medical societies, public and private providers of health services, and the pharmaceutical industry, among others.

Despite the many efforts in the region, with limited financial resources, hypertension control is still far from adequate, particularly among vulnerable groups. But improvements are possible and there are successful examples (⁶6. Fontil V, Gupta R, Moise N, Chen E, Guzman D, McCulloch CE, et al. Adapting and Evaluating a Health System Intervention From Kaiser Permanente to Improve Hypertension Management and Control in a Large Network of Safety-Net Clinics. Circ Cardiovasc Qual Outcomes. 2018;11(7):e004386. doi: 10.1161/CIRCOUTCOMES.117.004386.
https://doi.org/10.1161/CIRCOUTCOMES.117... ). These experiences have not been sustainable nor scalable in many countries. Although there have been advances in understanding and promoting change at the medical, technical, and scientific levels, little has been done to promote political and systemic change.

The purpose of this paper is to address this political gap by engaging the region’s civil society, which has been successful in changing policies to address other risk factors. Despite the enormous burden of disease that hypertension represents, civil society has had limited involvement in its control or in reducing the resulting social and economic inequities. In this paper we propose strategies that might enhance the success of existing initiatives through a more active involvement of civil society organizations (CSOs) advocating for sustainable and scalable hypertension control. We propose the engagement of the region’s vibrant civil society community, familiar with strategies for policy change, to make a crucial difference installing the prioritization of hypertension in the political agenda, ensuring sustainable funding, and expanding the demand for action from the community.

RECOMMENDED STEPS FOR CIVIL SOCIETY INVOLVEMENT TO IMPROVE HYPERTENSION CONTROL

Analyze the political landscape to design an advocacy plan

Civil society has a critical role in developing a comprehensive landscape scoping analysis (⁷7. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. 'Doing' health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan. 2008;23(5):308-17. doi: 10.1093/heapol/czn024.
https://doi.org/10.1093/heapol/czn024... , ⁸8. Brugha R, Varvasovszky Z. Stakeholder analysis: a review. Health Policy Plan. 2000;15(3):239-46. doi: 10.1093/heapol/15.3.239.
https://doi.org/10.1093/heapol/15.3.239... ), which includes a combination of legal (policy) analysis, policy mapping, and stakeholder mapping to help determine an appropriate advocacy plan. Components of a comprehensive scoping analysis are described below. The intent is to inform on the local context, needs and opportunities for policy change. When considering a landscape analysis for hypertension, it is important to focus on what policies/resources are available to support adequate diagnosis and sustainable treatment and control, and its integration in the primary health care system that is accessible for vulnerable populations. A landscape analysis for hypertension includes the following elements:

Legal analysis.

A comprehensive review of whether national and subnational binding policies and/or recommended guidelines exist that address operationalizing hypertension diagnosis, treatment and control. Frequently, existing policies/guidelines may be insufficient and lead to obstacles to reducing hypertension prevalence. As part of the legal analysis, it is important to review how governments officially address (a) Health coverage systems, to understand who pays or benefits from universal health coverage in the population; (b) Mechanisms for primary health care delivery; (c) NCDs prevention strategy and whether hypertension is incorporated into the NCD framework as a national priority; (d) Appropriations that are built into fiscal policies that cover hypertension diagnosis, and affordable medicines for all groups; and (e) If appropriations for hypertension exist, mechanisms to track allocation, disbursement, spending, and reporting to ensure transparency and accountability.

Policy mapping.

Reviews whether there are binding policies/guidelines supporting the operationalization of hypertension care within the government.

Stakeholder mapping.

Identifies allies within and outside of the government. It includes, but is not limited to government officials, academics, relevant health-based groups—such as cardiology and other medical societies—, population-specific groups, and international cooperation donors and funders.

Allies within the government can serve as champions who may provide administrative or political support in advancing fiscal/political decisions around hypertension resource allocation. It is necessary to identify influencers and/or policy champions who have information, can provide technical support, and will be able to sponsor needed changes. Understanding their interests and perceptions (e.g., patient rights or budgets) strengthens the probabilities of success.

CSOs may also have an integral role in activating government officials and identifying how the resources may improve local access issues around diagnosis, treatment and control. Additionally, CSOs may have an integral role in raising awareness outside of the government (i.e., public, media and critical audiences), to eventually lead to an increased uptake of existing services.

Identifying obstacles.

This includes identifying the main barriers and opponents. While the barriers to access hypertension diagnosis, treatment and control may be similar across countries (⁴4. Jeemon P, Séverin T, Amodeo C, Balabanova D, Campbell NRC, Gaita D et al. World Heart Federation Roadmap for Hypertension – A 2021 Update. Global Heart. 2021;16(1):63. doi: 10.5334/gh.1066.
https://doi.org/10.5334/gh.1066... ), it is particularly important to understand the magnitude of those barriers nationally, as well as potential solutions. When disseminating messaging around barriers to critical audiences, it is important to highlight the greatest bottlenecks, as this is where there may be a need to devote the most resources. While it may seem there are no opponents to reducing hypertension, all those with a stake in the current system may oppose change. This includes the medical community, the healthcare system, businesses profiting from the present situation, and the pharmaceutical industry, among others.

Community mapping.

Identifying the best community intervention strategies contributes to improving health outcomes and promoting community advocacy. This mapping may include community-based health education programs (⁹9. Lu CH, Tang ST, Lei YX, Zhang MQ, Lin WQ, Ding SH, et al. Community-based interventions in hypertensive patients: a comparison of three health education strategies. BMC Public Health. 2015;15:33. doi: 10.1186/s12889-015-1401-6.
https://doi.org/10.1186/s12889-015-1401-... ), those providing financial and administrative support, social mobilization, and community health centers working in detection, diagnosis, treatment and patient management (¹⁰10. Xiao N, Long Q, Tang X, Tang S. A community-based approach to non-communicable chronic disease management within a context of advancing universal health coverage in China: progress and challenges. BMC Public Health. 2014;14(Suppl 2):S2. doi: 10.1186/1471-2458-14-S2-S2.
https://doi.org/10.1186/1471-2458-14-S2-... ). When individual demands for medical care are insufficient, community advocacy experiences should be promoted (¹¹11. Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Public Health. 2010;100(Suppl 1):S40-6. doi: 10.2105/AJPH.2009.184036.
https://doi.org/10.2105/AJPH.2009.184036... ). These can be identified and documented as success stories.

Risk assessment.

Few realize the enormous health, economic and social burden caused by hypertension, and the impacts of not addressing the problem. This should be clear to policy makers, the media, and the public, not in the language of medicine and science, but in language accessible to public understanding. Furthermore, the information should be based on national data, where available (health, epidemiological, economic).

Based on the findings from the landscape analysis, civil society groups, working with key allies, can then prioritize the policy goal(s) and advocacy strategy for advancing sustainable and scalable hypertension care.

Define the policy goals and supporting advocacy strategies, based on the landscape analysis

Defining the policy goals is essential to avoid duplication and complement existent efforts, filling the gaps and reducing the political and social barriers. Sustaining equitable health and well-being of the population is a role of government and the policy goals defined by civil society must be in line with promoting the government’s role and responsibility.

In general, and based on experience, we recommend the following two main policy goals as essential elements for civil society engagement: securing the necessary resources for hypertension care services and increasing the utilization of those services. Policy goals should be clear and narrowly defined.

Secure necessary resources for hypertension diagnosis, treatment and control as a priority in the political and funding agenda.

Consider a comprehensive advocacy strategy towards authorities and politicians by (a) Building political will for prioritizing hypertension care in the NCD and comprehensive primary health care systems; and (b) Seeking adequate and sustainable funding for hypertension screening, treatment and control for the entire population, particularly for the most vulnerable groups. In many countries hypertension may not be recognized/allotted adequate resources under any fiscal policy. CSOs can advocate policymakers and key government officials to secure appropriate funds as part of annual fiscal budgets. In addition to securing funds, mechanisms should be put in place for tracking budgets to ensure transparency and accountability in allocation, disbursement, spending, and reporting. To improve the reach to vulnerable population groups, budgets should specifically earmark funding for scaling up hypertension care and hypertension drug procurement and delivery mechanisms, including but not limited to improving access to effective and affordable medicines.

Strengthening community awareness, increasing the social demand for action, and utilization of services.

Higher utilization of services and resources can make the case for sustaining and/or increasing budget allocations in subsequent budget cycles. This community-based advocacy would include (a) Building coalitions that include patient organizations, their families, and community grassroots organizations to increase the appropriation and ownership of hypertension as a top priority; (b) Collaborating with public health organizations, scientific/medical institutions to increase the relevance of hypertension in their advocacy agenda; and (c) Engaging academic organizations to improve hypertension content in graduate and postgraduate curricula for training health professionals and implementing research to identify effective interventions in primary care settings and the community

Develop and implement an advocacy plan with strategies and tactics to achieve the goals

A robust advocacy plan includes, but is not limited to, decision-maker advocacy, coalition building, media advocacy, and monitoring and countering opposition. There is much experience and evidence about the tools, narratives, resources, and activities that are effective to build a compelling case, to target different audiences, and put the issue on the public and political agenda. The following strategies provide a systemic approach to advancing a comprehensive advocacy plan.

Build the case for support.

To impact relevant audiences (i.e., policymakers, media, public and public interest groups, academics, other CSOs), it is critical to consider how to reach them through clear and compelling messages based on scientific evidence (¹²12. Majone G. Evidence, Argument & Persuasion in the Policy Process, New Haven: Yale University Press; 1989.). A compelling case about the health, economic, and/or social impact of hypertension may be made to address specific audiences. Clarifying the nature of the problem and the proposed solutions helps make a case for prioritizing hypertension, and the funds needed. Some key elements for the narrative include hypertension control to protect the right to health; the need to reduce inequities and protect the most vulnerable; and accountability mechanisms from the government to procure affordable medication and increase access to treatment, particularly for the poorest population. Consider de-medicalizing the topic so that it can be understood by the general population in simple language.

Decision maker advocacy.

As part of the stakeholder mapping, CSOs may be able to identify key champions within the government who can provide administrative or political support in advancing fiscal/political decisions around hypertension resource allocation. As part of decision maker advocacy, these champions can be engaged regularly to identify the need to support efforts around hypertension care at the highest political level. Policy maker advocacy also involves technical support/assistance in advocating for and implementing best-practice measures.

Media advocacy.

It involves disseminating critical information to audiences, keeping in mind the messaging, the messengers, packaging of information, and distribution channels. Through media advocacy, CSOs can build awareness to advocate for both political support and to increase public uptake of primary care services. Media advocacy enables the use of various platforms, including paid and earned traditional media and social media, to disseminate preventive messages, with self-diagnosis tools, identification of medical services, etc. Often, CSOs work with professional media groups for distributing messaging across all channels to broaden the reach.

Coalition building.

CSOs can support local leaders by building robust, engaged coalitions, utilizing their extensive networks to identify and attract new partners, improving health literacy and understanding of their rights in the process. A coalition of collaborative partners build off each other's strengths to further advance civil society's capacity. Through strategic planning and mobilization, coalitions can further contribute to policymaker advocacy, media advocacy, and monitoring and countering opposition.

Monitoring and countering opposition.

CSOs may monitor, expose, and counter potential opponent tactics by, for example, identifying conflicts of interest. In addition to mapping opposition as part of the landscape assessment, CSOs may encourage decision makers to exclude individuals/groups participating for personal gain (i.e., financial, prestige) from policymaking forums; hold opponents accountable for hindering population health efforts; and expand partnerships to counter these tactics by providing appropriate messages, tools and capacity building.

Demand accountability from government

CSOs can also play the role of a “watchdog” to monitor and ensure effective and transparent implementation of policies once they have been approved. This role may include:

Budget/resources accountability.

This may involve ensuring that the funds and resources are provided and used as intended.

Shadow reporting.

While governments frequently are required to report on approved policies, they have an interest in showing success. Shadow reports and evaluation by CSOs are helpful in publicizing what has been done, and what is left to be done.

Citizen audits.

There are community efforts in our region to monitor health services to identify what may be improved. These may include interviewing administrators, healthcare providers, patients and their families (¹³13. Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud (CEGSS), Guatemala. Available from: https://cegss.org.gt/ Accessed March 29 2022.
https://cegss.org.gt/... ).

Crowdsourcing.

With smartphone applications widely available, community monitoring can be widespread by tapping the power of patient groups, students, and others to monitor even hard to reach health centers and populations (¹⁴14. Zhang J, Cui X, Liu H, Han H, Cao R, Sebrie EM, et al. Public mobilisation in implementation of smoke-free Beijing: a social media complaint platform. Tob Control. 2019;28(6):705-711. doi: 10.1136/tobaccocontrol-2018-054534.
https://doi.org/10.1136/tobaccocontrol-2... ).

Another advocacy tool is strategic litigation to protect human rights, right to health, compliance with policies, or other established rights. Strategic litigation may address “liberty and security of the person; privacy; information; bodily integrity; life; the highest attainable standard of health; freedom from torture, and cruel, inhuman and degrading treatment; participate in public policy; and non-discrimination and equality.” (¹⁵15. Talbot S. Advancing human rights in patient care through strategic litigation: Challenging medical confidentiality issues in countries in transition. Health Hum Rights. 2013;15(2):69-79.)

CONCLUSIONS

Civil society in Latin America is already a main player in addressing policy change at the population level such as reducing dietary sodium, front of package food labeling, promoting school nutrition, and other interventions that help prevent hypertension. Civil society can support hypertension control, complementing the many activities initiated by the HEARTS Initiative, through comprehensive political and community work.

The special set of skills required for policy change may be applied to further advance prevention and treatment of hypertension. To jumpstart efforts in advocacy, it is necessary to build ownership and capacity within civil society, which, to date, has perceived this issue as medical. This community has already transferred skills from tobacco control policies to nutrition policies and, more recently, towards alcohol control efforts. With project funding, it will take on this challenge.

A policy advocacy approach to hypertension control and the engagement of a community knowledgeable in advocacy for policy change will not only support improved care, health, economy, and quality of life outcomes but it will contribute to reaching the 2030 Sustainable Development Goals and advance universal health coverage.

Disclaimer.

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization.

Acknowledgements.

We thank Dr. Pedro Ordunez, PAHO, who has consistently encouraged civil society engagement in hypertension prevention and control.

REFERENCES

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