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Pioneering a multidisciplinary, multisector urban health approach to improve the control of hypertension as a key risk factor for cardiovascular disease

Better Hearts Better Cities: a multisector approach to improve cardiovascular health in low-income urban communities

Von Roberta Bosurgi

The Novartis Foundation recognizes that hypertension is a key risk factor for cardiovascular diseases (1) that can be treated effectively. Complex interactions between urbanization, unhealthy lifestyles, the growing burden of noncommunicable diseases and weak primary health systems are best addressed in an integrated, multisector way. Through Better Hearts Better Cities, the Novartis Foundation is working with local authorities, and a network of partners to co-develop sustainable interventions to strengthen systems and create innovation beyond the healthcare sector.

Better Hearts Better Cities: a multisector approach to improve cardiovascular health in low-income urban communities

Over 10 million people are estimated to die from hypertension globally every year (Photo: Brazil © Novartis Foundation)


The global challenge of NCDs and hypertension

70% of the world's 56 million annual deaths are caused by NCDs such as cardiovascular disease, diabetes, respiratory disease and cancer, and over 75% of these occur in low- and middle-income countries (2: WHO. Noncommunicable Diseases Progress Monitor). Managing NCDs is a huge challenge for health systems in such countries because they also still face a high burden of infectious diseases. In addition, current development aid is almost exclusively directed to addressing infectious diseases and maternal and child health issues, while less than 2% of the total development funding is allocated to fighting NCDs (3: Institute for Health Metrics and Evaluation. Financing Global Health).

Over 10 million people are estimated to die from hypertension globally every year (4: Olsen et al., Lancet Commission on hypertension). Being the prime risk factor for cardiovascular disease, hypertension is often referred to as the “silent killer” because it remains asymptomatic until complications occur. If left unaddressed, hypertension leads to heart disease, stroke or kidney failure. Although significant evidence exists on how to prevent, treat and manage hypertension, it continues to be poorly controlled, especially in low- and middle-income countries, where health systems are ill-prepared to provide chronic disease care. Patients with NCDs also face several barriers to care, because of a lack of access, affordability or acceptability of the care they need.

Urban health in low- and middle-income countries

Rapid and unplanned urbanization has changed how populations experience health in cities around the world. People living in cities increasingly lead lifestyles characterized by unhealthy nutrition, reduced physical activity, stress, excessive alcohol and tobacco consumption. All these are well-known risk factors for developing NCDs (5: Reddy, Cardiovascular diseases in the developing countries, 6: WHO Global Report on Urban Health). Addressing these underlying risk factors is complex, especially in low-income urban communities, where the scale and pace of urbanization can often outpace the already under resourced city infrastructure and health services, thereby further deepening existing inequity.

Rapid and unplanned urbanization has changed how populations experience health in cities around the world (Photo: Brazil © Novartis Foundation)

 

These challenges are systemic and cannot be tackled by one organization alone. Only by working together with local and global partners across a range of sectors, can we design holistic solutions for healthier cities and communities. To truly thrive, cities must become ecosystems of health and wellbeing, where each part works towards one goal: extending and improving people’s lives.

Better Hearts Better Cities

Better Hearts Better Cities is a Novartis Foundation initiative to improve cardiovascular health in low-income urban populations.  Better Hearts Better Cities seeks to achieve this through a multisector approach addressing hypertension and its underlying risk factors in a sustainable way at scale. Through its focus on hypertension, Better Hearts Better Cities aspires to reimagine the way chronic diseases can be prevented and managed, as an example that can be applied to other noncommunicable diseases.

Ulaanbaatar in Mongolia, Dakar in Senegal and Sao Paulo in Brazil have been selected to be the first wave of cities, based on high unmet cardiovascular health needs and the strong commitment of local authorities to improve cardiovascular health

Global and local partnerships for urban health

To achieve its goals, Better Hearts Better Cities aims to build a network of partners, reaching beyond the health sector. Partners can include healthcare providers, but also digital and telecommunication organizations, food suppliers, employers, insurance funds, social enterprises and civil societies. Made up of both public and private organizations, the network is intended to operate on a global level, connecting the intervention sites with shared knowledge and expertise and, at the local level, implementing evidence-based interventions.

The Novartis Foundation plans to leverage its knowledge of working with partners to pioneer new models for healthcare delivery, based on programs such as the Ho Chi Minh City Communities for Healthy Hearts program and the Community-based Hypertension Improvement Project (ComHIP) in Ghana.

Active participation and buy-in from the local government is vital not only to build a network of implementation partners, but to achieve longer-term impact and sustainability in strengthening the health system. Therefore, from the beginning, local authorities are in the driver’s seat and own the design of the program in their city.

Better Hearts Better Cities is a Novartis Foundation initiative to improve cardiovascular health in low-income urban populations (Photo: Senegal © Novartis Foundation)


Intervention strategies

Together with stakeholders, the Novartis Foundation is working on core implementation strategies in five areas of focus:

  1. Strengthen primary healthcare quality to better manage hypertension
  2. Improve people-centeredness and coordination of care
  3. Leverage the patient as an agent of change through education and empowerment
  4. Strengthen equitable access to drugs 
  5. Address underlying determinants of cardiovascular health by creating healthier living and working conditions

The key areas of focus for Better Hearts Better Cities are determined by each city’s needs and insights from the multisector partners. The first step in setting-up the operations is to conduct an assessment of the health system in its current state. Based on that evaluation, interventions are then co-designed together with the local health authorities and other partners.

Implementation arrangement and governance model

The most important condition for the success of Better Hearts Better Cities is that the local government embraces the vision of the initiative and takes ownership. City authorities are encouraged to commit resources to the design and implementation of interventions and to integrate cardiovascular health in the different aspects of the urban agenda, while identifying resources for long-term ownership and scale-up of interventions that prove successful.

Measuring success

The success of Better Hearts Better Cities is planned to be assessed by its impact on the health of low-income urban communities and by its long-term sustainability. Evaluation is coordinated across the sites by an international academic partner that, in collaboration with local evaluation institutions, independently assesses the results and outcomes of the interventions. We plan to apply learnings from Better Hearts Better Cities in the three demonstration cities to the other sites, and shared with the global health community. As we learn what does and does not work following this multisector approach to address hypertension, we can create an approach for chronic disease prevention and care, particularly in low-income urban communities.

By 2050, it is estimated that two-thirds of the world’s population will live in urban areas. As a result, we have no time to lose to understand how cities can become positive instruments of public health, so that we can slow the epidemic of noncommunicable diseases and help urban populations live healthier lives.

References

  1. Angell, De Cock & Frieden (2015). A public health approach to global management of hypertension. The Lancet 2015; Volume 385, No. 9970, p825–827. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62256-X/fulltext
  2. World Health Organization. Noncommunicable Diseases Progress Monitor (2017). http://apps.who.int/iris/bitstream/10665/258940/1/9789241513029-eng.pdf?ua=1
  3. Institute for Health Metrics and Evaluation. Financing Global Health 2013: Transition in an Age of Austerity. Seattle, WA: IHME, 2014. https://ncdalliance.org/why-ncds/the-financial-burden-of-ncds
  4. Olsen, Michael H et al. (2016). A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension. The Lancet, Volume 388, Issue 10060, 2665 - 2712. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31134-5/abstract
  5. Reddy KS (2001). Cardiovascular diseases in the developing countries: dimensions, determinants, dynamics and directions for public health action. Public Health Nutr 2001;5:231–7. https://www.cambridge.org/core/journals/public-health-nutrition/article/cardiovascular-diseases-in-the-developing-countries-dimensions-determinants-dynamics-and-directions-for-public-health-action/6C3601AE1A4EAFCC6B92FA62936C6A4E
  6. World Health Organisation (2016). Global report on urban health: equitable, healthier cities for sustainable development, page 82. http://www.who.int/kobe_centre/measuring/urban-global-report/en/
Roberta Bosurgi

Roberta Bosurgi works at Novartis Foundation and is the Head of the Urban Health Initiative. She is responsible for setting up a new multi-disciplinary collective initiative for hypertension in low income urban settings.