Improving implementation of innovations in treatment for cardiovascular disease in low- and middle-income settings: The IMPLEMENT-CVD Study (Renewal)

Context and challenge being addressed Low- and middle-income countries have experienced an exponential rise in mortality from cardiovascular disease. Most of these deaths are caused by uncontrolled high blood pressure, or hypertension (blood pressure > 140/90 mm Hg), driven by gaps in implementation of evidence-based treatment. Fixed-dose combination therapies (2-3 blood pressure-lowering medications combined into one pill) offer one potential solution for addressing known barriers to treatment of hypertension. The advantages of fixed-dose combinations over individual pills include improvements in adherence and meeting blood pressure targets, reduced health care costs, and fewer cardiovascular events (e.g. heart attack). Yet, despite strong clinical evidence and promotion in international guidance, fixed-dose combinations for hypertension are not widely or consistently implemented. To date, very little is known about the broader health system factors affecting implementation of fixed-dose combinations for hypertension in low- and middle-income countries. Aims and objectives The overall aim of my Future Leader Fellowship is to improve implementation of fixed-dose combinations in low- and middle-income countries. The first phase of my Fellowship focused on Kenya and The Gambia. I achieved my objectives to identify health system barriers to implementation of fixed-dose combinations and to co-develop, with local stakeholders, a strategy to improve implementation of fixed-dose combinations. In February 2025 I will be piloting and evaluating the feasibility of this strategy in Kilifi, Kenya, and Kiang West, The Gambia. For the renewal phase of my Fellowship, my objectives are: 1. To generate evidence for policy-makers of the economic and health value of the proposed implementation strategy that I am piloting (Work Package 1); and 2. To develop a systematic Plan of Action to promote adoption of the strategy into policy (Work Package 2). For Work Package 1, we will use cost data collected during the feasibility study. We will conduct a Cost-Effectiveness Analysis of the implementation strategy to be compared against a willingness-to-pay threshold and a Budgetary Impact Assessment for national and local governments. We will also go beyond these anlayses to conduct a Value of Implementation Analysis. Value of Implementation is an emerging field that explicitly addresses health system costs incurred to facilitate policy change and effective implementation by comparing the net monetary benefit generated in a Cost-Effectiveness Analysis with the costs of implementation and scale-up. For Work Package 2, I will use methods from Applied Political Analysis. This will include Stakeholder Analysis of a wide range of stakeholders in hypertension treatment policy, using in-depth qualitative interviews and workshops. I will work closely with the Cardiac Societies in both Kenya and The Gambia to develop a Plan of Action to support policy adoption that is informed by the power, positions, and interests of relevant stakeholders. Potential applications and benefits The implementation strategy co-developed in the first phase of my Fellowship could greatly improve hypertension treatment in Kenya and The Gambia. To do so, it must be adopted into policy and scaled-up. The work that I am proposing will generate evidence for policy-makers about the costs and value of investing in this strategy and will develop a concrete, evidence-based plan to promote its adoption into policy. It will also build capacity for health systems research for cardiovascular disease in the UK, Kenya, and The Gambia, and provide an approach to policy-making engagement that can be adapted by cardiovascular disease researchers to other settings.