Background

Hypertension is the leading cause of death globally. The condition affects about 1.4 billion adults and is the main risk factor for cardiovascular diseases (CVD) [1, 2]. The management of hypertension improves cardiovascular population health, reduces early mortality and avoidable hospitalizations [2,3,4]. 70% of people with hypertension live in low- and middle-income countries, where health systems are largely focused on the delivery of services for acute healthcare needs, as opposed to managing chronic conditions amenable to prevention. The latter requires long-term sustained engagement and interaction between patients, healthcare professionals and the health system to efficiently manage conditions [5], improvement in event-free survival along with better quality of life, and medical cost reduction. To achieve these goals, the identification of specific barriers and needs related to effective hypertension control is required to develop targeted interventions and spark the necessary transformation of health systems and their services delivery models [6].

Like many other countries across the globe, Brazil has undergone a major shift in its epidemiological profile; burdened historically by infectious diseases, the country’s main public health challenges today stem from non-communicable diseases (NCDs) [7]. The increase of NCDs observed in Brazil and elsewhere was precipitated by an increasingly sedentary lifestyle and changing eating habits, leading to a high prevalence of obesity and other CVD risk factors [2, 8]. In 2016, CVDs were the leading cause of morbidity and mortality [9]. A recent study exploring hypertension prevalence in different South American countries found a 53% prevalence among 5,557 Brazilians aged 35 to 70 years from both rural and urban settings [10]. Investing in corrective and preventive behavioural approaches in the face of ever-increasing treatment expenses has become a priority for the government [11, 12]. Studies have shown that the Brazilian primary health system should be strengthened in the area of disease management pathways (including for NCDs) with a people centred perspective [13].

The challenges of NCDs, as in other parts of the world, also impact São Paulo city, Brazil’s most populated city, despite the constant efforts of local health authorities to reduce their prevalence and burden [14, 15]. In São Paulo, the prevalence of hypertension in the adult population has been estimated to be 23.2% in a telephone-based survey [16]. However, the same survey found large variability in prevalence within the adult population; in people aged 50 to 69 years of age, the prevalence of hypertension varied from 34.5 to 51.3%. In São Paulo city, half of the population depends on Brazil’s unified public health system (Sistema Único de Saúde; SUS), which, among other services, provides universal coverage and access to free medication [17]. Through different initiatives and reforms, the public health program for São Paulo focuses on the reduction of mortality due to NCDs and includes hypertension management. Prominent examples are the NCD Strategic Action Plan to which São Paulo state adhered to, the tobacco control laws, salt reduction policies and public sport facility programs, which all have relevance for municipal planning of priorities [18, 19]. A study from 2011, investigating care pathways of already diagnosed hypertensive patients in the public health care sector of São Paulo, documented a treatment adherence level of 20% [20] and that 35–50% of patients treated for hypertension had their blood pressure controlled [20, 21]. These findings reveal opportunities to increase treatment adherence, quality of care, access to medicines, patient follow-up and care coordination [14].

The initiative Better Hearts Better Cities (entitled “Cuidando de Todos” in Brazil), applying the CARDIO (Care, Access, policy Reform, Data and digital, Intersectoral collaboration and local Ownership) approach [22], was designed as a multidisciplinary, multisector initiative to support local authorities in addressing urban cardiovascular population health, including hypertension as primary risk factor. The initiative was implemented in Ulaanbaatar, Mongolia; Dakar, Senegal; and São Paulo, Brazil. In Brazil, the initiative was executed in collaboration with the São Paulo Municipal Health Secretariat (Secretaria Municipal de Saúde; SMS-SP). This partnership aimed at co-creating and accelerating the implementation of a model to approach NCDs. The implementation methodology was guided by a Design Thinking approach [23]. The current article details the diagnosis step of the methodology, which focused on assessing the primary needs in the public health system in São Paulo. The identified needs of patients, healthcare professionals and the health system with respect to hypertension diagnosis, treatment and control will be presented.

Methods

Setting

São Paulo city is one of the five most populous metropolis in the American continent and the largest financial and corporate centre in Latin America [24]. São Paulo was recently included in the “Global Cities of the Future 2021/2022”, occupying the fourth place of the ten “Megacities of the Future” with the best strategies for attracting foreign direct investment [25]. With more than 12 million inhabitants on 1,521 km2 [26], São Paulo was selected for the implementation of Better Hearts Better Cities. Reasons include the range of opportunities to improve hypertension and CV risk factor control, São Paulo’s urban characteristics such as the close co-existence of high-, low- and middle-income features, the developed health system (SUS) and the complexity of urban management, especially in health [27]. After agreeing to jointly execute the initiative, the SMS-SP selected the districts of Itaquera and Penha to host the first implementation.

Conceptual approach to problem identification

In São Paulo, the initiative was implemented between 2018 and 2020 in the stages of groundwork, diagnosis, exploration, co-creation, implementation and scale-up. This initiative followed a Design Thinking process [23], using the double diamond approach [28]. Besides factual roadblocks and concrete challenges, the Design Thinking process also considers latent needs of the health system. These needs may be abstract and emotional and, as such, can be difficult to express or to recognize in traditional needs assessments [29]. To address this, Design Thinking focuses on the analysis of the end-user and beneficiary perspective in a clarification step (here referred to as situational analysis). Information collected in this step through interviews and shadowing is essential to frame key issues correctly, identify opportunities for improvement and ideate adequate solutions [30], which can be subsequently implemented in partnership with the local health authorities. This situational analysis and its results of the health care ecosystem’s needs for patients, healthcare professionals and the system itself are described in the current manuscript. The process used to conduct this situational analysis is aligned with the recommendations of the World Health Organization (WHO) HEARTS package [31] and the World Heart Federation [6].

Primary health care structure in São Paulo

The situational analysis took place in 2018 in the district of Itaquera and in 2020 in the district of Penha. These districts were selected due to their representativeness of low- and middle-income communities. Additionally, primary healthcare units (Unidades Básica de Saúde; UBS) with different health system management models are present in these districts; the primary health care network of São Paulo is composed of 450 UBSs (traditional model) [32] and 117 outpatient medical care centres (Assistência Médica Ambulatorial; AMA) [33], of which 87 are integrated with a UBS [34]. The UBS network is staffed by different types of primary care teams (Equipes de Atenção Básica; EAB), including those organized according to the family health strategy (Estratégia Saúde da Família; ESF), a Brazilian management model of primary care delivery [35]. In Brazil, the organization, management and execution of services and activities of primary health care is the responsibility of the municipality. In São Paulo, health facilities can be directly managed by the SMS-SP (direct administration) [36, 37] or, alternatively, the management can be delegated to social organizations (e.g. cooperatives), private companies, non-governmental or philanthropic organizations [38]. Table 1 depicts the characteristics related to primary care infrastructure in Itaquera, Penha and São Paulo city as a whole.

Table 1 Characteristics of São Paulo and the two participating districts, Itaquera and Penha. Data extracted from TabNet São Paulo of the SMS
Full size table

Situational analysis procedures

The situational analysis was conducted by a team composed of members of the Novartis Foundation (global initiative coordinator), the Instituto Tellus (local implementation partner), the São Paulo Society of Cardiology (Sociedade de Cardiologia da Cidade de São Paulo; SOCESP), as well as members of the SMS-SP. The municipal authorities approved the initiative and its strategy, and took ownership for the execution, facilitated communication with internal stakeholders, helped establish a first technical working group and identified the first implementation districts. The SMS-SP assigned the initiative to the chronic diseases and NCD care (Doenças e Agravos Não Transmissíveis; DANT) technical department. This department was created in 2018 to elaborate a municipal care protocol for NCDs and harmonize the use of different national and international guidelines by physicians in the public health system of São Paulo. Thus, the initiative fully supported the priorities of the SMS-SP.

With this governance established, the team started the first part of the situational analysis by addressing health system components with a focus on primary care delivery. The investigation was conducted at the SMS-SP, in order to understand health system building blocks, such as governance, importance of and priority given to primary care, currently available resources and gaps, data management priorities and available information management systems, current guidelines, their application, and the policy landscape. Special consideration was on other programs related to hypertension in Brazil, and recent initiatives to address other chronic diseases such as diabetes. To complement this information, the team conducted a review of the available literature and municipal data concerning CVDs for São Paulo.

Secondly, continuous follow-up discussions with the NCD technical department at the SMS-SP supported the contextualisation of the findings from the first part of the analysis. Inter-disciplinary workshops with relevant partners (e.g. SMS-SP, public officials representing primary care and/or NCD management, district health care delivery, medical societies, global initiative coordinator, local implementation partner, international scientific partners) were conducted to further deepen the understanding of the health system concerning diagnosis, treatment and control of hypertension. The discussions clarified the relation of municipal strategy to operational execution in the UBS in terms of technical decisions, perception and execution of best practices.

Finally, a total of nine UBS (six in the district of Itaquera and three in the district of Penha) were selected by the SMS-SP to be included in this situational analysis and undergo a thorough investigation using several data collection tools.

Data collection approaches and tools

To gain deep knowledge and understanding of the entirety of the health system, a mixed-methods approach based on the Design Thinking process [23, 39] and the AEIOU framework (Activities, Environments, Interactions, Objects, and Users) was pursued [40]. In addition to the use of these frameworks, to gain a complete understanding of the conditions and potential for interaction with the population in and beyond the health system, other than primary health care unit workers, the team also included relevant focal points within the district, such as community champions (e.g. samba and football club, spiritual leaders) and reference points (e.g. shopping mall, high traffic venues, green areas). Table 2 presents the type of information collected from the different stakeholder groups to help pinpoint unmet needs at primary care level. This was executed using three tools targeting different respondents based on their role in the health system:

  1. 1)

    An online form consisting of open- and closed-ended questions was applied to collect data for an initial diagnosis of the needs in each UBS (Supplementary files 1 and 2; one for Itaquera and one for Penha). An online version of the online form was sent to the UBS managers who were invited to complete it. The online form covered, among other topics, physical and personnel structure of the UBS, use of digital technology, data collection and recording tools and service time of each professional. Additionally, there were a few questions, targeting the work conducted by the community health agents (CHAs), regarding their knowledge around hypertension, their degree of patient engagement, their knowledge on use of medication, and their practice in encouraging healthy lifestyle behaviour. Between the implementation of the online form in Itaquera and Penha, it underwent some adaptations and fine-tuning based on the experience in Itaquera; hence, there were two versions of the online form (Supplementary files 1 and 2).

  2. 2)

    Conversation circles (n = 43) were carried out with UBS staff and patients in the UBS offices. For each respondent category, a specific conversation guide with lead questions was available. The goal was to, in each UBS, include one person from each of the following categories: (i) patient; (ii) doctor; (iii) nurse; (iv) community health agent; (v) pharmacist; (vi) admission officer; (vii) UBS manager, and (viii) school health programme manager. Participants were from the same district and selected by the UBS. Additionally, the situational analysis team included experts in the area of cardiovascular health, population health and health systems, among which were directors of medical societies such as SOCESP, NCDs forum [41] and representatives of the Brazilian Ministry of Health.

  3. 3)

    Shadowing was conducted by members of the implementation team who observed two CHAs from one selected UBS throughout their day of work [40]. The main goal of this approach was to understand the relationship between CHAs and hypertensive patients. Additionally, CHAs were asked about their beliefs, attitudes and perception of hypertension, as well as about their observations and perceptions on the population’s diet and physical activity in the context of the disease cluster. Observations and responses were recorded using a standard data collection form (Supplementary file 3).

Table 2 Main topics investigated in the situational analysis and from whom the information was collected through online forms, key informant conversation circles and/or shadowing
Full size table

Data analysis

The information gathered by the implementation team using online forms, conversation circles, shadowing activities and government workshops, was compiled, tabulated and systematized by Instituto Tellus. This provided a first assessment of the existing needs, which resulted in two main outputs. The first was a patient care journey map, investigating the interactions between patients and the primary care team and mapping challenges and opportunities. This map served as an interactive and iterative tool during data collection, allowing for the visualization of details of the system through which patients with hypertension navigate and, therefore, helped clarify needs and bottlenecks present at different stages of the patient’s journey. The second main output was a matrix presenting the identified needs presented along three major components (i.e. patients, healthcare professionals and health system) for the diagnosis, treatment and control stages of hypertensive patients.

The gaps identified during this step were taken up in the co-creation sessions with the city health authorities, members of the American Heart Association (AHA), SOCESP and other primary care practitioners for refinement and to brainstorm for solutions. This process has been described in detail elsewhere [23]. All results were discussed and validated by the SMS-SP, which confirmed the adequateness and provided further input.

Results

All nine UBS managers who were asked to respond to the online form returned it and all 30 people who were planned to include in conversation circles attended.

The nine pilot UBSs were representative of the different UBS administrative models of the Municipality of São Paulo: two traditional UBS, four AMA integrated with a UBSs, and three UBSs with ESF. Of these, one of the traditional UBS was under direct administration and the remaining eight were managed by a social organization. These UBSs served between 12’000 and 39’964 people. The operational models, management types, number of people and adults covered and years in operation for each of the nine UBSs are presented in Table 3. The newest UBS had been in operation for 10 years, whereas the oldest had been established 45 years ago. In terms of data collection systems, all UBS used SIGA Saúde (Sistema Integrado de Gestão de Assistência à Saúde de São Paulo) for the registration of patients’ appointments and to record basic data, and Gestão de Sistemas de Saúde (GSS; Health system Management), which is the medicines logistics system. It was also found that all nine UBSs had an integrated pharmacy.

The analysis of the results from the nine pilot UBSs revealed that, to improve the quality of the data collected, the online form needed to be revised. Questions that were found to not bring relevant insights were removed, (e.g. “how many functioning printers does your UBS have?”), while additional questions were introduced to fill data gaps noticed.

Table 3 Overview of characteristics of investigated primary care units
Full size table

Patient care journey map

The results from the online forms, conversation circles and shadowing of CHAs were consolidated and mapped out in the patient care journey map (Supplementary file 4: Figure 1), which catalogues the structure of the observations of primary needs along a timeline. The starting point of each overlapping journey was a research-based fictional persona that represented a particular group (i.e. patient, community health agent, doctor, pharmacist, nurse) [42]. Each persona’s journey started with a short description of the official requirements from the Brazilian comprehensive health and nutrition promotion practices in primary healthcare (Práticas Integrais de Promoção da Saúde e Nutrição na Atenção Básica; PINAB). The journey also showed explicit and latent needs. By visually exposing the information collected, the team was able to trigger discussions among health managers, clinical team members and health authorities and to understand whether the results obtained by the implementation team corresponded to the actual needs experienced by healthcare professionals and managers. This map helped identify several opportunities on how to improve the patients’ experience. Those participating in the exercise reported that it was the first time this complex system of interactions was depicted in a visual way and was, thus, insightful to gain oversight of paint points, process overlaps and opportunities to optimize team work.

Main needs and barriers identified

The mapped barriers for the different CVD management stages (i.e. diagnosis, treatment and control) for patients, healthcare professionals and the health system resulting from the pilot phase are presented in Table 4. Conversation circles found, for instance, that the patients’ knowledge and awareness of the importance of hypertension risks and of regularly measuring blood pressure was poor, particularly in men and young people. According to patients, these issues, coupled with a poor understanding of the treatment and problems in the health system such as insufficient staff, in turn, according to health professionals, led to low adherence to treatment. From the patient perspective, for successful control of their blood pressure, they needed a stronger bond and a good relationship with the health staff to increase their engagement.

From the perspective of healthcare professionals, there was a lack of training, and the quality in medical record entries required attention. Concerning treatment, healthcare professionals felt that the training of CHAs on the topic of NCDs, the motivation provided to patients and the quality of guidelines needs to improve. As an example, hypertension was diagnosed following the 7th Brazilian guideline [43], but the situation analysis revealed that due to the complexity of the guideline, those best-practices are only partially applied. Concerning the control of hypertension, the presented findings showed that healthcare professionals needed more time with patients to explain treatment in detail, but also highlighted some of the inefficiencies in the health system that would need to be resolved.

Concerning the health system, a perception that 15-minute appointments were too short and that this negatively impacted both the diagnosis and treatment steps was mentioned by both health professionals and patients. Finally, the system also lacked clear goals and action plans when it came to diagnosis, treatment, and control (i.e. follow-up of patients).

For each of the needs and barriers identified for patients, health professionals and the health system (Table 4), brainstorming sessions led to the outlining of prototype solutions. These prototype solutions later underwent a selection phase and were developed into the solutions that were implemented; these final solutions are presented in a second publication in this series of publications on the Better Hearts Better Cities initiative in Brazil.

Table 4 Needs for hypertension services captured by stage and by stakeholder level
Full size table

Discussion

The situational analysis and its findings were the first steppingstone of the Design Thinking process used in the urban population health initiative, Better Hearts Better Cities, in São Paulo city. The data captured on health system components and different stakeholders, such as patients, healthcare professionals, managers and decision-makers, has led to the identification of several needs relating to the diagnosis, treatment and control of hypertension in low- and middle-income settings. Findings were used as a basis for the design of specific interventions targeting the identified needs, which were subsequently taken up and implemented.

The analysis showed that the patient’s perspective encompassed elements connected to disease awareness (specifically regarding men and youth), self-care (including no standard possibility to track disease status, low adherence, missing follow-up medical appointments, and low motivation), difficulties of patients to engage in the care process, build an emotional connection to primary care teams, and lack of consistent early detection and standards of care. For healthcare professionals, needs in optimizing and clarifying guideline-based care, treatment and follow-up, improving information management (e.g. quality of medical record and completeness of documentation), enhancing standard continuous training programs on disease and treatment, and reinforcing team-based care were identified. From the health system perspective, potential was seen to define structured processes to upgrade efficiency, and establish defined treatment and care delivery goals with a focus on outcomes, action plans and applicable guidelines and tools on diagnosis, treatment and control. All the findings of this situational analysis were later confirmed during an expansion phase of the same methodology implemented in another 18 UBS in Itaquera and 18 UBS in Penha. Additionally, the results of this analysis are in line with roadblocks identified by entities such as the World Heart Federation [6] or the Organisation for Economic Co-operation and Development [44]. Hence, it is assumed that the identified challenges including primary care management, patient pathway/journey, and workforce up-skilling are transferable to other geographies and health systems.

To our knowledge, this work is the first that displays the health system in São Paulo or even Brazil, its team structures, responsibilities, and needs on a comprehensive patient journey map. This situational analysis found that, although aware of the complexity of the health system, the visualization of the journey map gave health system managers and healthcare professionals a new perspective on the system that they navigate daily. This provided valuable insights for discussion of opportunities and challenges to address latent and explicit needs, process optimization and task-shifting.

In the context of this urban population health initiative, we evaluated the existing gaps in the healthcare system by engaging with health professionals and patients. This situational analysis provided valuable insights that directly fed into the design of specific interventions and further informed the CARDIO4Cities approach. The CARDIO4Cities approach, which stands for Care, Access, Policy Reform, Data and Digital, Intersectoral Collaboration, and Local Ownership, as described by Aerts and Boufford [22], was developed based on these insights. This comprehensive situational analysis aided in identifying the specific needs and opportunities within the healthcare system, enabling the development of targeted interventions. The implementation of the CARDIO4Cities approach in São Paulo, guided by the São Paulo health authorities, has been proven to be impactful [45, 46]. We believe that a precise understanding of the situation and the healthcare system’s needs is crucial for devising tailored strategies to improve cardiovascular health. During the diagnostic phase, the information gathered through this situational analysis was used to co-create a total of 14 solutions in collaboration with various stakeholders. The objective of these solutions was to reform hypertension management, optimize healthcare delivery, and increase cardiovascular population health.

This process described in the paper showed that despite being resource-intensive due to the assessment being embedded in the primary care context and its daily operation, the methodology led to findings that were perceived to be focused on core needs of the beneficiaries, namely the patients, healthcare professionals, managers and decision-makers and as such were meaningful, endorsed and accepted as appropriate. The findings allowed for the development of sustainable interventions, enabling local stakeholders to feel fully involved and empowered in the whole process. This focus on actual needs is a major strength of the approach, which was reinforced by the bottom-up analysis of the situation. Another strength is that this initiative was able to bring together all types of stakeholders in a participatory and inclusive manner making sure all voices were heard. Finally, the careful selection of the pilot UBSs, whereby every administration model was represented, was of great importance.

Limitations of this work include that the first version of the online form was too complex for respondents and, therefore, it needed to be adapted. Consequently, the composition of questions asked to UBS managers slightly differed between the two districts. Moreover, the team realized, at the start of the project, that some stakeholders felt they might be judged by what they mentioned, feeling observed and showing some discomfort when it came to sharing any bottlenecks in the system. This hesitancy was, most likely, a result of previous negative experiences where the same stakeholders participated in projects without ever seeing any outcomes or benefits. Thus, it was fundamental to clarify that the aim was to build a partnership offering a safe space to share any issues, in a constructive manner. Finally, it was not always easy to obtain consistent data on CVDs from the different stakeholders as there were several sources to collect the data from. Lastly, the rapid staff turnover at the SMS-SP was, at times, limiting the efficacious progress of the analysis.

Conclusions

Despite all the efforts the SMS-SP has put into reducing the burden of hypertension in São Paulo city, its prevalence remains high and its control remains low. This situational analysis, conducted in close collaboration with SMS-SP, allowed the Better Hearts Better Cities initiative to apply an innovative methodology to identify opportunities for improvement within the health system and established an operational baseline for boosting the diagnosis, treatment, and control of patients with hypertension living in low- and middle-income settings of São Paulo city. In doing so, it laid the foundation for the design of solutions and successful roll-out and expansion of the project. Based on the experience and results from both the pilot and expansion phases, the team recommends the use of this methodology in future studies that aim at identifying needs within a health system based on a well-defined focal area. Employing bottom-up, collaborative, inclusive and needs-focused approaches drives change management, reinforces sustainability and up-take of solutions in the implementation phase.