The primary objective of this "good practice" initiative is to address the increasing morbidity and mortality rates associated with cardiovascular diseases. These efforts align with the Government of Bermuda's commitment to providing universal healthcare and improving access to affordable health services for all residents. Recognizing that an estimated 12% of the population lacked health insurance, the Government of Bermuda took steps to close this gap in healthcare access. In 2021, the Hamilton Health Centre, the island's sole public primary health facility, began offering clinical services for patients with non-communicable diseases, particularly hypertension and diabetes. In January 2023, with support from the Pan American Health Organization, the Government launched the HEARTS in the Americas initiative in response to the low blood pressure control rates observed in 2022. A key focus of the initiative by the government was the introduction of the Hypertension Clinical Pathway, with a standardized treatment algorithm. The government sought to make antihypertensive medications defined on the treatment algorithm available at no cost to uninsured and underinsured patients. This was supported by interventions to ensure accurate blood pressure measurements, team-based care and strengthening of monitoring and evaluation. Over the course of three years, the number of clients in the hypertension registry grew to 110, representing a fivefold increase from 20 clients in December 2022. Blood pressure control rates improved significantly with control rates increasing from 25% at baseline to 62% by 24 months, based on measurements taken at six-month intervals. This improvement in blood pressure control, led insured individuals (approximately 36%) to seek care at the clinic as well. This practice offers a model that can be replicated in countries or territories where healthcare is predominantly private and where a segment of the population faces challenges accessing affordable care. The use of a standardized treatment protocol allowed for procurement of a smaller variety of antihypertensives, implementation of a team-based approach for distribution of medication and easier titration of medications. This facilitated rapid blood pressure control. Additionally, the streamlined distribution of antihypertensive medications at the point of care provided easier access to medications and reduced the risk of stockouts and wastage.
The overarching goal of this initiative is to reduce the morbidity and mortality rates associated with non-communicable diseases (NCDs). To achieve this, the Government of Bermuda aims to expand and enhance the accessibility of high-quality healthcare services for individuals living with NCDs, who may not be able to afford it. This desire commenced with the distribution of antihypertensives, defined on the standardized treatment protocol, to patients with hypertension and uninsured or underinsured, free of cost at the Hamilton Health Centre. Specific objectives: 1) To commence a hypertension and diabetes clinic at the Hamilton Health Centre for patients with Hypertension and Diabetes who are uninsured and underinsured. 2) To improve Blood Pressure Control amongst patients attending the Hamilton Health Centre. 3) To provide antihypertensives (in keeping with the standardized treatment algorithm) free of cost, at point of care, to uninsured and underinsured patients accessing care at the Hamilton Health Centre.
The initiative in Bermuda was implemented through a phased approach. The timeline of the initiative's implementation is as follows: 1. 2021: Pre-Implementation The Hamilton Health Center, the island’s sole public primary healthcare facility began offering a hypertension and diabetes clinic to individuals who were uninsured and underinsured. Health promotional activities commenced, and the communities were alerted, primarily by word of mouth, that these services were being offered at the Hamilton Health Centre. Attending clients were encouraged to tell others about the services. 2. July to December 2022: Planning phase This phase focused on sensitization of health care practitioners and acquiring baseline data for the implementation of HEARTS in the Americas. A short situational analysis was developed. 3. January to June 2023: HEARTS in the Americas Implementation This phase focused on establishing essential procedures and processes. Amongst these was the creation of a standardized treatment algorithm as a part of the Clinical Care Pathway to support the management of hypertension. The national standardized acceptable treatment protocol was defined as Telmisartan 40mg and Amlodipine 5 mg as first line; the dosage was doubled as second line. Chlorthalidone 12.5 mg was added as third line and the dosage doubled as fourth line. If above target, the patient was referred to the next level of care. 4. July to December 2023: Optimizing the standardized treatment protocol During this phase, the emphasis was placed on optimizing the standard treatment protocol. The Government of Bermuda made all medications included in the treatment algorithm available free of charge to patients attending the facility. A team-based care approach was taken where the nurses distributed the antihypertensives in keeping with the standardized treatment algorithm at the point of care. 5. January to June 2024: Enhanced Monitoring of Indicators In this phase, efforts were focused on improving monitoring and data collection. This included the expansion of the current Excel document, which functioned as a de facto hypertension registry. DHIS2 was introduced. 6. July to December 2024: Identification of improvement strategies for better blood pressure control During this final phase, efforts were made to identify strategies for increasing the number of clients attending the facility on a regular basis (target 200) and continued improvement in Blood pressure control (target 80%). 7. January – June 2025 (ongoing): Implementation of hypertension drivers. Although good progress was being made, the need to achieve the desired control rate resulted in the implementation of the hypertension drivers, particularly the review of uncontrolled patients within 2-4 weeks. This has since resulted in the expansion of the number of clinic days and the review of the registry to begin eliminating clients who are insured and have achieved blood pressure control to maximize the visits for those patients who are uninsured and underinsured.
Summary of Main Results: The overall results clearly demonstrate achievement in the objectives identified above in the government’s goal to promote equity in the accessibility of health care services. To date, 110 clients are registered at the public primary health care facility and the numbers continue to grow. As of December 2024, Blood Pressure Control amongst clients treated was 62%. However overall, the number of clients in the registry that had a BP reading in 6 months was still way below the target of 80% (31%-52%). 1. Increasing number of clients in the registry: The Ministry of Health launched the chronic disease clinic in 2021, with 20 clients enrolled by the end of December 2022. This number quadrupled within one year following the implementation of HEARTS (n=86). The registry has continued to grow annually, with a clientele of 110 at the end of December 2024. Initially focused on the uninsured and underinsured, the clinic's success in controlling blood pressure led insured patients to seek services at the health facility as well. 2. Steady registration of new clients with uncontrolled blood pressure: There has been a consistent influx of new clients seeking clinical services. The number of new clients registered and managed at 6, 12, 18 and 24 months respectively when compared to previously registered clients were 81% (21/26), 38% (17/45), 36% (17/47), and 26% (9/34). Of these new clients, one-third and fewer had controlled blood pressure upon presentation. 3. Increasing percentage of patients with Blood Pressure control: There has been a steady increase in the percentage of clients with controlled blood pressure. By the end of December 2024, 62% of clients had blood pressure levels below 140/90, a notable improvement from 25% at the beginning of the treatment protocol's implementation. Blood pressure control levels amongst those treated at 6,12,18 and 24 months were as follows: 46% (12/26), 56% (25/45), 47% (22/47) and 62% (21/34). 4. Increasing Use of the Treatment Algorithm: As of the latest data, at least 60% (64/107) of registered clients are on the standard treatment algorithm regimen. With each successive phase, the percentage of clients adhering to the treatment protocol has increased, from 62% to 74%.
1. Limited Appointment Availability: Initially, the healthcare team at the Hamilton Health Centre allocated one afternoon per week to cater specifically to patients with non-communicable diseases (NCDs). However, as the number of patients increased, appointment slots quickly became overbooked. This challenge is currently being addressed by adding an additional afternoon session to accommodate the growing demand. 2. Frequent Transition Between Private and Public Healthcare Services: Due to the frequent movement of patients between private and public healthcare services, blood pressure monitoring and follow-up appointments are often missed, hindering consistent monitoring of controlled blood pressure levels. While this helps integrate the treatment algorithms into the private sector, it impacts the accessibility of care for the target population. To mitigate this, blood pressure monitoring books were procured to facilitate ongoing self-monitoring by patients, particularly those visiting both private and public healthcare providers. 3. High Cost of Combination Fixed-Dose Medications: Bermuda has recognized that combination fixed-dose medications provide maximal therapeutic benefit. However, the high cost of these medications has been a significant barrier. 4. Comprehensive Implementation of HEARTS and the Clinical Pathway: While this "good practice" initiative has focused on adhering to the standardized treatment algorithm, it is important to acknowledge that maximizing blood pressure control requires the full implementation of HEARTS and the Clinical Pathway for Hypertension. This comprehensive approach is essential for achieving optimal long-term outcomes and maximizing blood pressure control. An analysis revealed that there was limited implementation of the hypertensive drivers. The number of clients on the treatment algorithm who was uncontrolled and was seen within one month, during the six month evaluations, ranged from 8% to 45%. Efforts are currently underway to put a recall mechanism in place.
Enfermedades no Transmisibles y Factores de Riesgo
The resources allocated for the implementation of this Good Practice were used efficiently, with significant attention to cost-effectiveness. The Government of Bermuda was able to procure the single dose antihypertensives on the treatment algorithm at a very low cost. Additionally, the following benefits were achieved: • Standardized Treatment Protocol: The adoption of a standardized treatment protocol facilitated the procurement of a smaller variety of antihypertensives and is anticipated to reduce the risk of stockouts and wastage. Additionally, the streamlined distribution inclusion of these medications in the Bermuda Drug Formulary enables regulation of the drug prices, reducing the 20% subsidy required from consumers, making medications more affordable in the long run. • Task shifting: Efforts were made to enhance the capacity of the registered nurse to efficiently dispense medications at the point of care, improving the overall accessibility and continuity of treatment. • Improvement in Blood Pressure Control: One-third and less of new patients presented with controlled blood pressure levels, consistent with the findings from the latest STEPS survey, which indicated that 33% of the general population had adequate blood pressure control. Improvement in the Blood Pressure control reduces cardiovascular risk. • Cost-Effectiveness of HEARTS Interventions: Early results suggest that HEARTS hypertension control interventions are either cost-saving or cost-effective. The HEARTS package costs between US$18-44 per person per year, with antihypertensive medications priced low enough to reach a global standard of under US$5 per patient per year in the public sector. In Bermuda, the cost of the antihypertensive medication to the Government, is even lower for patients on the treatment algorithm at the Hamilton Health Centre.
Currently, HEARTS in the Americas is being implemented as a health system strengthening model across nearly all countries in the region. A core element of the HEARTS program is the Clinical Care Pathway, which integrates the Standardized Treatment Protocol. While substantial success has been achieved within the public health system, there is limited data regarding its application in the private sector. In Bermuda, implementing this approach poses challenges as healthcare is predominantly delivered through the private sector. HEARTS in the Americas has limited experience in the private sector. Engaging private entities in health system strengthening efforts is often difficult, as participation cannot be mandated. However, the rising rates of morbidity and mortality from cardiovascular disease is now a public health issue and must be addressed nationally. Recognizing this, Bermuda initially focused on strengthening clinical care management for cardiovascular disease within the lone public health centre, but efforts are underway to extend this initiative to the private sector. Capacity-building sessions have already been held, and private clinics have already been approached to implement the HEARTS program. The initiative in Bermuda has successfully reached not only the uninsured and underinsured but also the fully insured populations, thanks to improvements in blood pressure control. Patients with blood pressure control rates are now moving between private and public primary care facilities. This success demonstrates the program's high quality of care and broad appeal. This practice provides a replicable model for countries or territories with predominantly private healthcare systems, where a segment of the population struggles to access affordable care. As part of its expansion, the initiative is exploring further collaboration with private physicians. Does the development of the GP have adaptability and replicability potential? The core intervention components of this initiative involve the introduction of a standardized treatment protocol, with medications provided free of charge primarily to the uninsured and underinsured populations. The key implementation components of this good practice focus on the cost of medication. Efforts are being made to address this challenge through the regulation of medication prices to consumers and the continued procurement of the medication at a very low cost. In addition, as access to medications continues, there will be a need for expansion of human resources to manage the increased demand for services. Supporting Adaptability and Replicability: 1. HEARTS in the Americas is already being implemented in almost all countries in the region, providing a strong foundation for replicating this practice. 2. The introduction of the Standardized Treatment Protocol Algorithm for hypertension management is a best practice recognized by the World Health Organization. 3. The use of the protocol is easily replicable, with a focus on sensitization and capacity building, consistent with the adaptation of new healthcare guidelines. This will ensure consistent use of the protocol across all healthcare workers. 4. While the cost of amlodipine + telmisartan combinations in Bermuda is high, the Government of Bermuda was able to procure single doses at a very affordable cost. 5. The selection criteria for medications have been established, ensuring the most appropriate treatment options are provided. 6. Program adaptations have been considered where individual medications are used as the dual combination drugs were too costly.
1. Government Funding: The Government of Bermuda is providing the funding for this initiative as part of its commitment to achieving Universal Health Coverage. This ensures the long-term financial support needed for the continued success of the program. 2. Distribution of Treatment Protocols: The treatment protocols have been printed and distributed to healthcare providers, ensuring consistent application and adherence to the standardized guidelines across the healthcare system. 3. Long-term Impact on Treatment Adherence: Once it has been demonstrated that the Clinical Care Pathway improves blood pressure control, patients are unlikely to revert to their initial antihypertensive medications. This improvement in care is expected to lead to sustained better outcomes and treatment adherence. 4. Adaptation of Standard Operating Procedures (SOPs): Standard Operating Procedures (SOPs) are being adapted to reflect best practices, ensuring the smooth implementation of the initiative across both public and private healthcare settings. 5. Ongoing Monitoring and Evaluation: There is a strong focus on ongoing monitoring and evaluation to assess the impact of the initiative. The DHIS2 tool is being used to track progress and ensure data is accurately collected for continuous improvement. 6. Pan American Health Organization (PAHO) Leadership: The initiative is being led by the Pan American Health Organization (PAHO) across all countries in the Americas, providing guidance and support to ensure the initiative’s sustainability and effective implementation at a regional level. 7. The continued growth of the hypertension clinic cannot be sustained as more clients become aware of the services offered. Efforts are underway to consider engaging in public-private partnerships. Once the insured patient receives adequate blood pressure control, they are removed from the active registry and encourage to continue visiting the primary care physician at regular intervals.
Challenges faced during implementation: 1. Limited Appointment Availability: Initially, the healthcare team at the Hamilton Health Centre allocated one afternoon per week to cater specifically to patients with non-communicable diseases (NCDs). However, as the number of patients increased, appointment slots quickly became overbooked. This challenge is currently being addressed by adding an additional afternoon session to accommodate the growing demand. 2. Frequent Transition Between Private and Public Healthcare Services: Due to the frequent movement of patients between private and public healthcare services, blood pressure monitoring and follow-up appointments are often missed, hindering consistent monitoring of controlled blood pressure levels. While this helps integrate the treatment algorithms into the private sector, it impacts the accessibility of care for the target population. To mitigate this, blood pressure monitoring books were procured to facilitate ongoing self-monitoring by patients, particularly those visiting both private and public healthcare providers. 3. High Cost of Combination Fixed-Dose Medications: Bermuda has recognized that combination fixed-dose medications provide maximal therapeutic benefit. However, the high cost of these medications has been a significant barrier. 4. Comprehensive Implementation of HEARTS and the Clinical Pathway: While this "good practice" initiative has focused on adhering to the standardized treatment algorithm, it is important to acknowledge that maximizing blood pressure control requires the full implementation of HEARTS and the Clinical Pathway for Hypertension. This comprehensive approach is essential for achieving optimal long-term outcomes and maximizing blood pressure control. An analysis revealed that there was limited implementation of the hypertensive drivers. The number of clients on the treatment algorithm who was uncontrolled and was seen within one month, during the six month evaluations, ranged from 8% to 45%. Efforts are currently underway to put a recall mechanism in place. HEARTS in the Americas is aligned with “Better Care for NCDs”, which represents a key milestone in a country’s health system response to the Sustainable Development Agenda, with the aim of leaving no one behind. Lower socioeconomic status can limit access to healthcare, particularly in private insurance-based systems such as Bermuda. Individuals may choose not to seek care due to cost or to delay care, which may inadvertently result in higher healthcare costs for more complex manifestations of conditions. Ultimately, this can result in what is known as the Inverse Care Law, in which people with the greatest health needs are the least likely to receive the necessary healthcare. In Bermuda, like other high-income countries, the leading causes of mortality over the 10 years pre-pandemic were chronic non-communicable diseases. Diseases of the circulatory system (33%) and neoplasms (cancers) accounted for approximately 60% of deaths annually. Availability of health insurance is tied to employment status, Bermudian status, and previous pattern of residency. This limits access to healthcare for the unemployed population or those aged 65 years and older without access to affordable health insurance. The 2016 census identified 8% of the population as uninsured, with a further 17% only having basic coverage13. Worsening unemployment during COVID-19 has led to revised estimates of 12% of the population being uninsured and a further 23% having only basic cover or unaffordable insurance premiums. Thus far only 15 (14%) of the patients on the hypertension register at the Hamilton Health Centre is 65 years and older. Co-payments are also likely to play an important barrier in patients accessing healthcare, with out of-pocket payments for both healthcare visits and associated products’ costs (including medicines) preventing patients from seeking care until conditions are more serious. At system-level, health inequalities may be driving additional healthcare costs, as people with significant health needs are unable to access cost-effective chronic disease management in primary care, instead relying on more expensive episodic emergency treatments that are ultimately ineffective for long-term health outcomes. Therefore, to reduce cardiovascular risk and limit complications and reduce mortality associated with cardiovascular disease, it is therefore essential that emphasis is placed on identifying patients with hypertension and maintaining good blood pressure control amongst patients diagnosed. Hypertension is the top modifiable contributor to the mortality and morbidity associated with cardiovascular disease.
As countries advance towards the achievement of the Sustainable Development Goal (SDG) 3, which aims to ensure healthy lives and promote well-being for all at all ages, including ending preventable deaths, achieving universal health coverage, and combating diseases, PAHO/WHO continues to provide support to accelerate actions towards the established target of reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. Recognizing that cardiovascular diseases (CVD) in the Caribbean are estimated to contribute to roughly 38% of all NCD-related deaths, and hypertension is a major modifiable risk factor, PAHO/WHO was extremely supportive of efforts being made to mitigate against the impact of uncontrolled blood pressure and its associated complications and high healthcare costs. As highlighted in the 2014 STEPS survey in Bermuda, about one-third of the population had raised blood pressure, which is a major risk for CVD. This data underscores the importance of taking steps to manage hypertension effectively, as it is a major contributor to premature death and disability. To address this, the World Health Organization (WHO) has proposed standardized hypertension management intervention protocols. These protocols aim to foster better blood pressure control and prevent cardiovascular disease through several strategies. In addition to these efforts, a standardized approach to managing hypertension is expected to yield other benefits including improved monitoring and surveillance, better quality of disease burden data and economic impact mitigation. The Pan American Health Organization (PAHO) have further adapted these guidelines into the "HEARTS in the Americas" initiative. This program supports countries in developing and implementing clinical guidelines and strategies to manage hypertension, with the goal of achieving blood pressure control rates of 80% in health facilities. Bermuda is therefore working closely with PAHO to implement “HEARTS in the Americas”. Several key factors were carefully considered during the planning phase of the technical cooperation initiative. These included, but were not limited to, the limited availability of public health clinics, a significant uninsured population facing high healthcare costs, and the long-term sustainability of the initiative. Each of these elements played a crucial role in shaping the strategy to ensure both immediate impact and lasting effectiveness. As previously discussed, approximately 12% of Bermuda’s population lacked health insurance. In response, the Government of Bermuda has taken significant steps to address this gap in healthcare access, particularly for patients with non-communicable diseases such as hypertension and diabetes. In the most recent report from the Chief Medical Officer, attention was drawn to the widening health inequalities in the post-pandemic era, where COVID-19 had a profound impact not only on health outcomes but also on the upstream determinants of health. The pandemic disrupted normal economic and social life, further exacerbating existing disparities. The report highlights that Bermuda continues to experience significant health inequalities, which are intricately linked to broader societal inequities, including socioeconomic status, race, sex, and migration status. One key issue identified is the lack of robust, population-wide data on health inequalities, especially data that can directly link health status with socioeconomic factors. This gap in data is crucial, as it prevents a deeper understanding of disparities and hinders targeted interventions. A critical driver of health inequalities in Bermuda is the current healthcare system, which lacks universal health coverage. As a result, those with the greatest health needs often struggle to access necessary care. This is a central issue that the Bermuda Health Strategy 2022-2027 aims to address. The strategy outlines the government’s commitment to achieving Universal Health Coverage, with a focus on reducing the barriers to healthcare access and ensuring equitable distribution of resources. The Bermuda Health Strategy 2022–2027 identifies the high cost of healthcare as the primary obstacle to ensuring equitable access to quality services for all. The strategy’s mission is clear: "To ensure that all people have equitable access to essential health services—informative, preventive, curative, rehabilitative, and palliative—of sufficient quality to be effective, while also ensuring that individuals do not face financial hardship when paying for these services or critical medications." As part of this effort, free access to healthcare and medicines at the Hamilton Health Centre represents an initial, tangible step toward achieving universal health coverage. Moreover, Bermuda’s 2013 health inequalities report revealed a significant gender disparity in healthcare utilization. It showed that women (80%) were more likely to visit their General Practitioners than men (65%). In response, targeted efforts have been made to encourage male participation in healthcare services, and as of today, approximately 47% of the hypertensive registrants at the Hamilton Health Centre are male, reflecting positive progress in engaging this demographic.
Universal Health Coverage; Delivery of Health Care; Access to Primary Care
| Caribe |
| Bermudas |
| Institución nacional (ministerio de salud, instituto de salud, laboratorio, etc.) |
| Intercambio de Conocimientos, Intercambio de Experiencias |
| Objetivo 3 - Meta 3.4 |
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