Bangladesh HEARTS: Lessons Learned from a National Hypertension Control Program, 2018–2026

Evidence-based treatment protocols

Adoption of a simple, linear, and drug- and dose-specific hypertension treatment protocol containing three of the most effective antihypertensive medicines readily available in the country is a key measure. The protocol (Figure 2) begins with amlodipine, a calcium channel blocker selected for its affordability, efficacy, and low risk of electrolyte imbalance, which eliminates the need for laboratory monitoring. If patient BP remains uncontrolled on amlodipine 5 mg alone, additional medicines are added, as per the protocol, at subsequent steps every four weeks until BP is controlled to <140/90 mmHg. Consistent with WHO treatment guidelines, the BP control target for patients with comorbidities such as diabetes, ischemic heart disease, stroke, chronic kidney disease, or high CVD risk is <130/80 mmHg. If the target BP is not achieved by step three and after confirming treatment adherence, patients are referred to specialist management.

Figure 2

Team-based care and task sharing

A multidisciplinary team of appropriately trained health care workers (HCWs) has strengthened and institutionalized hypertension diagnosis and management at the facilities. They work collaboratively at the NCD Corner under the supervision of a doctor. The team includes nonphysician members such as nurses, SACMOs, and pharmacists. Doctors are responsible for confirming diagnoses and initiating treatment in accordance with standardized treatment protocols. Nonphysician team members conduct patient screening, register new patients, document follow-up visits, refill medication, and provide counseling on medication adherence and lifestyle modifications. CHCPs also work in the community to increase screening, detection, referral, and follow-up of patients in selected CCs.

Medication and essential technology supply

A system has been established to dispense a 30-day supply of antihypertensive medications to all patients free of charge. Uninterrupted availability of medicine was ensured through strengthening the medicine forecasting and quantification system. All the NCD Corners were also equipped with validated digital BP measuring devices.

Patient-centered care

Service delivery elements have been incorporated to reduce barriers to treatment uptake, adherence, and retention. This includes universal BP measurement for all adults visiting the UHC, incorporating patient counseling and education on lifestyle modifications and medication adherence into routine clinic workflow, establishing systems for patient recall and follow-up to improve retention in care, decentralizing medication refills, and follow-up for stably controlled hypertensive patients at CCs to reduce barriers to access and alleviate congestion at the UHCs.

Information systems

A user-centered, smartphone-based health information system (the Simple mobile app) is being used to collect and manage a limited set of patient data longitudinally, enabling rapid feedback loops using program data and performance monitoring (12).

NCD Corner activation

To facilitate access to hypertension treatment, the government reactivated existing NCD Corners and made them the center of hypertension treatment service delivery at each UHC. The NCD Corners at each UHC are located on the ground floor close to the facility entrance for accessibility, have ample space to accommodate waiting patients, and adequate space to allow service delivery (9). The Government of Bangladesh renovated and equipped each NCD Corner with one arm-in heavy-duty digital BP device with a printer; two portable validated digital BP measuring devices; one aneroid BP machine; a weighing scale; a stadiometer; a measuring tape; chairs and desks; filing cabinets; and Information, Education, and Communication material display boards. A multidisciplinary team of appropriately trained HCWs collaborates at the NCD Corner under a doctor’s supervision to establish team-based care and task sharing. All steps are performed by appropriately trained nonphysician HCW team members, except for diagnosis and treatment initiation, which are performed only by a doctor.

Screening, diagnosis, and treatment

Opportunistic screening for raised blood pressure among all people aged 18 years or more visiting the center is carried out by nurses at NCD corners. The physician confirms the diagnosis and initiates treatment in accordance with the hypertension management protocol for PHC settings.

Record keeping and follow-up

Diagnosed patients are enrolled in the Simple app digital health information system and assigned a follow-up date one month later. Patients visit the NCD Corner monthly on the designated date for follow-up and medication refill.

Free medicine and longer refill duration

Patients receive one month of prescribed medicine, free of charge, provided by the government. This reduces the number of visits patients must make to the UHC. Previously, facilities dispensed only 1–2 weeks of medication at a time; however, following a directive from the DGHS, patients began receiving a full month’s supply with each prescription and during follow-up.

Counseling

Nurses provide patients with targeted counseling on key aspects of hypertension management, including adherence to prescribed medications, the importance of regular follow-up visits, and practical healthy lifestyle advice.

Partnership and catalytic funding

The Government of Bangladesh recognized that it would need an effective model for hypertension management at the PHC level to treat the millions of people living with hypertension and achieve hypertension control targets. To accomplish this, the government partnered with the NHFB and RTSL to design, fund, and manage the BHCI program. The NCDC program provides strategic guidance and overall coordination, while the NHFB provides comprehensive implementation strategies, including policy engagement, monitoring and evaluation frameworks, supervisory mechanisms, and continuous quality improvement (QI) approaches. In addition, the NHFB also serves as the institutional hub for program management infrastructure. RTSL provides hypertension management expertise, access to the Simple mobile app digital information system, and technical guidance on program evaluation and QI activities.

The Government of Bangladesh provides facility infrastructure, BP monitors, antihypertensive medicines free of cost to patients, and HCWs’ salaries. RTSL’s supplemental catalytic funding provided a start-up supply of validated digital BP monitors, salaries of program management and supervisory staff, and funding for HCW training.

Situation analysis and protocol development

A comprehensive analysis of existing hypertension services, including epidemiology, treatment guidelines, protocols, and training materials, was conducted before implementation. An expert committee initially developed the national hypertension treatment protocol for PHC, which was subsequently approved by the Technical Committee to standardize care delivery across facilities (Figure 2).

Facility assessment

NCD service preparedness of health facilities was evaluated using an adapted WHO Service Availability and Readiness Assessment (SARA) questionnaire focusing on infrastructure, equipment, and staffing (13). Facility assessments conducted in 2021, during phase 2 at the sub-district level and including facilities from phase 1, reported that only 17.6% of facilities met the criteria to be considered service ready. Also, none of the facilities had a dedicated room for NCD management (14). Following the implementation, each facility now maintains a dedicated ‘NCD Corner’ for NCD management.

Hypertension management training and capacity building

To promote team-based care and ensure that all team members were adequately skilled in hypertension treatment (15), the program trained all relevant cadres of HCWs at the UHCs and CCs, including doctors, nurses, SACMOs, health inspectors, assistant health inspectors, storekeepers, statisticians, and community health care providers. These comprehensive training sessions covered the NCD and hypertension burden, hypertension diagnosis including appropriate BP measurement techniques, hypertension treatment according to the PHC protocol, patient follow-up and recall strategies, and establishing NCD Corner workflows to optimize BP measurement, patient care documentation processes, and data use for program improvement. Refresher training is held to account for staff attrition and knowledge loss over time.

Patient flow and clinical decision streamlining

To increase hypertension detection among patients visiting UHCs, all adult patients (18 years and older) are first directed to the NCD Corner for BP screening regardless of the reason for their visit. The program also adopted clear diagnostic criteria to facilitate early diagnosis and treatment initiation. If the initial BP is <140/90 mmHg and patients are not receiving antihypertensive medicine, they are regarded as normotensive. If, at initial screening, systolic blood pressure (SBP) is 140–159 mmHg and/or diastolic blood pressure (DBP) is 90–99 mmHg, patients are advised to return for a follow-up visit after two weeks for a repeat BP measurement. If the repeat BP is still above 140/90 mmHg, a diagnosis of hypertension is confirmed, and patients are enrolled in the Simple app. If, at the initial screening, SBP is ≥160 mmHg and/or DBP ≥100 mmHg, a repeat BP measurement is taken the same day to confirm diagnosis and start treatment immediately. Newly diagnosed hypertension patients are provided with one month of prescribed medicines free of cost and advised to follow up at the facility one month later. NCD Corner staff also provide advice for healthy lifestyle interventions to control high BP (Figure 3).

Figure 3

Systematic follow-up and reminder

To strengthen patient retention and improve adherence, the BHCI employs a dual strategy of digital and human outreach. Automated reminder messages are sent to patients who miss scheduled visits, resulting in a higher follow-up visit attendance rate and reducing delays in care (16). Complementing this system, BHCI operates a dedicated call center that conducts personalized phone outreach to patients with overdue or missed visits.

Information systems optimization

To ensure continuity of care, data use, and accountability for patient outcomes, the BHCI utilizes the Simple mobile app, an open-source, smartphone-based hypertension management information system also used in Ethiopia and Sri Lanka (12, 17). This digital system swiftly records patient data in about 83 seconds for new patient enrollment and less than 20 seconds for follow-up visits (18), which reduces HCW data entry time by approximately 20 minutes per day compared to the prior paper-based system. Simple’s offline-first feature allows functionality in facilities without internet connectivity. The software has two components: 1) an Android mobile phone app for health care providers to record patient BPs, prescriptions, and follow-up visit dates at every visit, which provides a longitudinal patient record and the capacity to monitor an individual patient’s response to treatment (Figure 4, Panel A); and 2) a web-based dashboard for health system managers at the facility, district, and national levels to monitor program performance trends and plan improvement efforts (Figure 4, Panel B).

Figure 4

The BHCI provided Android devices and monthly data packs for all facilities within the program area, enabling them to enroll patients using the Simple app at NCD Corners. At enrollment, patients provide their National ID card number and phone number, which are recorded on the Simple app, and each patient receives a paper hypertension program card (BP passport) with a QR code sticker. At return visits, HCWs scan the QR code with the Simple app to instantly retrieve patient records. The Simple app also generates a list of patients overdue for scheduled follow-up appointments and provides features for conducting secure telephone calls and sending automated SMS reminder messages. Facility and program managers utilize the Simple dashboard to manage resources, monitor patient demand, observe trends in key indicators, identify gaps in care, and track hypertension control rates across the region.

To promote focus on BP control and avoid overburdening frontline HCWs with reporting requirements, the BHCI chose to focus only on the most critical indicators needed to monitor program performance and patient outcomes. These include the number of people living with hypertension enrolled, the proportion with BP controlled, the proportion with BP not controlled, the proportion with missed visits, and patient days of medicines available per facility (definitions included in Supplementary Table S1).

Implementation monitoring and supervision

Implementation monitoring in the BHCI involves periodic, data-driven tracking of activities and outputs against planned targets to inform timely corrective actions. It uses tools such as dashboards, indicator matrices, and routine reports as demonstrated by the HEARTS360 framework, which translates large patient datasets into actionable insights (19). Insights derived from supervisory visit documentation and aggregated data also help identify implementation gaps and challenges. Government officials oversee the program through four committees: two policy-level committees for governance and alignment, and two operational committees for coordination and service delivery.

The BHCI supervision framework operates through a multi-tiered structure. At the frontline, Field Monitoring Assistants (FMAs) provide direct oversight and guidance to NCD Corner teams, aiming to enhance service delivery, ensure adherence to clinical standards, and build capacity through face-to-face engagement. At the intermediate level, Divisional Program Officers (DPOs) address administrative challenges, including drug stock monitoring and communicating with the call center. At the same time, Surveillance Medical Officers (SMOs) supervise FMAs, arrange feedback sessions and on-the-job training for NCD Corner team members, and provide technical support using structured tools such as the Simple dashboard and checklists to identify and address implementation gaps.

These officers maintain regular collaboration with facility, district, and divisional managers to resolve operational bottlenecks. At the national level, Program Directors oversee strategic supervision, engage with policymakers and stakeholders, and guide programmatic decisions, while ensuring capacity development of program staff. The BHCI’s supervision approach is inherently interactive, emphasizing real-time observation, contextual problem solving, and translating data monitoring into actionable improvements across the health system.

Quality Improvement

To further drive data use to improve patient outcomes and program performance, the BHCI introduced a systematic QI program embedded within supervisory structures at national, sub-national, and facility levels. DPOs and SMOs work with facility staff to review data on the Simple app to identify performance gaps, conduct root-cause analyses, plan and implement small tests of changes, and scale up successful interventions across all participating facilities. Program leadership meets monthly to review program performance and provide technical support and QI mentorship to local teams. Divisional and District Coordination Committees are responsible for providing QI oversight at PHC facilities. Monthly facility QI meetings are used to review data and develop iterative action plans. Outcomes of BHCI QI initiatives are provided in Table 3.

Medicine refills at community clinics

The BHCI piloted a decentralized antihypertensive medication refilling model across 107 CCs affiliated with five UHCs in the Sylhet district. This intervention targeted patients with controlled BP, enabling them to access medication refills directly from CCs rather than traveling to UHCs. No formal diagnoses or prescriptions were issued at CCs, which operate without on-site medical officers.

The pilot revealed that proximity to home and reduced waiting times made CCs more convenient and accessible for patients, contributing to improved service uptake. Monitoring data from the pilot sites indicated a BP control rate of 68% and a missed visit rate of 21%, compared to the district control rate of 57% and missed visit of 31%, underscoring the potential of community-based refilling models to strengthen continuity of care and optimize hypertension management.

Community-based HEARTS pilot

While the Bangladesh HEARTS trial focused on implementation at the UHC level, further evidence was needed of its effectiveness at the CC level. To address the challenges of serving a large number of hypertensive patients with a comparative shortage of trained physicians and nurses, and to reduce the burden of long-distance travel for monthly UHC visits for patients with controlled BP, a decentralized, team-based hypertension care model was piloted in CCs beginning in 2023. In this model, nonphysician staff screened and managed patients using HEARTS protocols under remote supervision from UHC Medical Officers via tele-consultancy. Conducted in four CCs under two UHCs in Jamalpur, the pilot screened 4,220 adults and enrolled 220 newly diagnosed, uncomplicated hypertension patients out of 244 eligible patients. The findings from this pilot are soon to be published.

Improvement of medicine quantification and forecasting

The Essential Drugs Company Limited (EDCL), operated by the Government of Bangladesh, supplies antihypertensive medicines based on demand estimates submitted by facility managers to the NCDC program. BHCI supervisory staff prepare the estimates using data that include patient volume and the proportion of patients on different protocol steps. This data-driven, prevalence-based process replaced the previous consumption-based quantification approach to help prevent stockouts and ensure consistent hypertension care at the PHC level.

Dissemination and documentation

Good practices, outcomes, and lessons learned are documented regularly and disseminated through national and district-level meetings with MoH&FW leaders, members of parliament, and health officials. Insights are also shared with policymakers and stakeholders to inform the scale-up and policy integration process.

Stakeholder engagement and advocacy

The BHCI has prioritized strategic collaboration across multiple governance levels to ensure adequate oversight and sustained stakeholder engagement. Facility visits and regular program progress updates are utilized to engage members of the Steering and Technical Committees, officials from the DGHS and MoH&FW, regulatory bodies, and local leaders, which contributes to strengthening institutional support and accountability.

To boost engagement, community programs were organized involving community groups, community support groups, and CHCPs. Participants received an introduction to NCD care at the UHCs and were encouraged to promote regular BP measurement, adopt healthy lifestyles, and use the NCD Corner services. Over 5,000 CCs benefited, resulting in increased BP screening, stronger referral systems, and expanded community awareness efforts.