Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and...

Area of Science:

• Public Health
• Cardiovascular Health
• Health Systems Strengthening

Background:

• Hypertension is a major cause of cardiovascular disease, disproportionately affecting people living with HIV (PLHIV) in low- and middle-income countries.
• Inconsistent hypertension screening and management within HIV care services in sub-Saharan Africa stem from poor readiness, low health worker motivation, and limited integration.
• Mozambique faces high rates of adult hypertension (39%) and HIV prevalence (over 13%), highlighting the need for integrated care solutions.

Purpose of the Study:

• To evaluate a scaled-delivery model of the Systems Analysis and Improvement Approach (SAIA) for hypertension management among PLHIV in Mozambique.
• To assess the effectiveness of integrating SAIA into existing district health management structures for hypertension and HIV care.
• To establish an evidence base for the national scale-up of SAIA for improved hypertension care delivery.

Main Methods:

• A stepped-wedge design with district-level randomization was employed across six districts in Maputo Province, Mozambique.
• The SAIA strategy was scaled up by district health supervisors and scaled out to 18 facilities over three 9-month intervention waves.
• Evaluation utilized the RE-AIM framework and aimed to estimate budget impact from the payer's perspective.

Main Results:

• The SAIA strategy provides user-friendly tools for frontline health workers to identify low-cost, contextually relevant improvement strategies.
• Integration of SAIA delivery into routine management structures is key to its effectiveness.
• The scaled-delivery model aims to improve hypertension care effectiveness, reduce patient drop-offs, and enhance service quality for PLHIV.

Conclusions:

• The pragmatic trial demonstrated that integrating SAIA into routine management structures is an effective strategy for national scale-up.
• SAIA facilitates decision-making by frontline health workers, leading to contextually relevant improvement strategies.
• This approach informs program planning and policy for scaling up integrated hypertension and HIV care services.