The World Health Organization (WHO) estimates that 17.9 million people die from cardiovascular diseases (CVDs) annually, and that CVD-related deaths will increase to 22.2 million annually by 2030 unless adequate preventive interventions and health care services are put in place.[1, 2] Hypertension, or clinically high blood pressure (BP), is the prime risk factor for CVDs, primarily strokes and heart attacks, which account for 31% of total deaths globally. WHO put forward ‘best buys’, including integration of services into primary health care (PHC) as part of a universal health care package and ensuring that medicines and counselling are available to those at risk for CVD. WHO defines a best buy as a highly cost-effective intervention that is feasible and appropriate to implement within the constraints of local health systems.
Although hypertension awareness and treatment have improved in high-income countries over the last decades, control remains a challenge. Low- and middle-income countries, meanwhile, are seeing growing incidence of the disease yet low rates of awareness and access to treatment.
In Vietnam, hypertension is a disease of increasing public health concern. WHO’s noncommunicable disease (NCD) country profile shows that the prevalence of hypertension in Vietnam has been rising since 2000. A recent systematic review identified a pooled prevalence of measured hypertension of 21.1% based on ten studies, and 18.4% based on three national surveys. Two other studies confirmed high rates amongst people 40 years of age and older. The first study, which investigated a population aged 40 to 69 years in central Vietnam, showed the hypertension prevalence was 44.8%. Another study, of people from 45 to 64 years old in Dien Bien Province, reported a prevalence of 35.5%. Hypertension was found to be significantly higher in urban than in rural areas (32.7% and 17.3%, respectively) and increased with age in both men and women.[10, 11]
In addition to the high prevalence of hypertension, the proportion of people in Vietnam aware of their disease status is unacceptably low, and the detection, diagnosis, treatment, and successful management of hypertension are limited: a 2012 study found that less than half of hypertension patients in the country were aware of their condition, and only 10.7% had achieved targeted BP control, defined as systolic blood pressure below 140 mmHg and diastolic blood pressure below 90 mmHg. In 2015, the Ministry of Health conducted a national survey on risk factors for NCDs amongst adults aged 18 to 69 using the WHO STEPwise approach to Surveillance (STEPS) protocol. Data from the survey showed that overall, 18.9% of a sample of 673 people had hypertension, but only 43.1% detected at screening were aware of their status. Of these, just 13.6% reported that their BP was being managed at a health facility. These significant gaps in the hypertension treatment cascade are attributed to limited awareness amongst the population of how to prevent and control hypertension, substandard health care worker capacity to detect and manage hypertension, and lack of convenient access to routine BP screening and hypertension prevention and medication adherence counselling.
Vietnam’s national strategy on prevention and control of NCDs (2015 to 2025) aims to detect 50% of those with hypertension and to treat and manage at least 50% of those diagnosed. The Ministry of Health also supports a national programme to improve hypertension prevention and control and has developed national standards and guidelines on management reflecting an important commitment to address the disease and a critical foundation for action. The role of commune health stations (CHSs) in reducing the burden of hypertension is considered essential for the national strategy, with increased screening and early detection and the provision of a continuum of care for hypertension support and management identified as key measures. In practice, however, Vietnam’s four-level health system is under-resourced to meet the needs of the population for hypertension prevention and care and has yet to demonstrate cost-effective service delivery models, particularly at the local level.
Considering the increasingly enforced requirement that users of the nationally sponsored social health insurance plan initiate care at the commune or district level , a critical opportunity exists to reinvigorate the commune health infrastructure. This will require CHSs to have well-trained personnel, be equipped with appropriate technologies and medicines, and be able to coordinate care with higher-level authorities and community case managers. This presents both an opportunity and an immediate challenge for patient-centred management of hypertension in Vietnam.
The Ministry of Health acknowledges that models are needed to demonstrate an effective and scalable hypertension detection, diagnosis, treatment, and management cascade. This involves increasing population awareness of CVD prevention as well as access to hypertension detection services; developing longitudinal care systems, including case management and patient registries; increasing health care worker capacity; and providing tools and guidance for those with hypertension to modify their behaviours and adhere to their treatment. An analysis of the 2015 STEPS survey recommended that strengthening NCD services at the PHC level was urgently needed for early detection, diagnosis, treatment, and management of hypertension. Against this backdrop, it should be noted that during the past decade, the private health care industry has grown exponentially, with a proliferation of private hospitals and clinics, small independent practices, and many businesses dedicated to health and wellness.
In 2016, PATH and the Novartis Foundation, in collaboration with Ho Chi Minh City Municipal Health Department and the Vietnam federal General Department of Preventive Medicine within the Ministry of Health, launched the Communities for Healthy Hearts (CH2) programme in Vietnam, a people-centred, community-based care model to introduce and test innovative approaches for BP control in the largest urban area of the country, Ho Chi Minh City. While hypertension screening and linkage to care programs have been introduced in LMICs, CH2’s unique multi-pronged model includes a focus on public-sector health services whilst also tapping into Vietnam’s growing private health care ecosystem to further extend the reach of PHC services, the use of digital technologies to ensure linkage to care, and the use community collaborators to support awareness, and increasing screening and retention in care. The impact of this model is seen in the increased screening and retention rates as compared to national averages. For example, between June 2016 until the end of the project in 2019, 121,273 individuals representing 58% of adults aged 40 years and older in the project catchment area had received an initial hypertension screening  as compared to 10%, as reported in the 2015 STEPS survey.
Similarly, CH2 study results, as described in the results and discussion sections of this paper, indicated that a greater percentage of those diagnosed with hypertension, initiated treatment and achieved BP control than was found in previous studies.
The paper explores the innovative components of the CH2 programme model and evaluates its operational aspects and effectiveness in expanding services for hypertension beyond the brick-and-mortar health care system.