Mapping the Dynamic Complexity of Hypertension Management in São Paulo, Brazil

Objectives: Hypertension is a major cardiovascular risk factor in Brazil and globally, requiring effective healthcare system strategies. This study examines how the health system in São Paulo manages hypertension, identifying patterns and connections that influence patient outcomes and resource use. Methods: Using literature reviews and participatory discussions with experts, we developed a systems map, causal loop diagram, to illustrate dynamic complexity underpinning hypertension management. Thematic analysis of qualitative data informed the model, highlighting key interactions that shape screening, treatment, and long-term care. Results: The analysis reveals critical dynamics at individual, community, and system levels. Early diagnosis and expanded treatment access improve adherence and reduce complications. However, these improvements also increase the number of patients needing long-term care. This creates a challenge where healthcare gains today can raise future demands if prevention efforts are underfunded. Conclusion: Understanding these interconnections is crucial for balancing treatment expansion with sustainable prevention strategies. By mapping system-wide challenges, this study offers a framework to help policymakers allocate resources more effectively and strengthen urban health systems. Future research will focus on using simulation modeling to test policy interventions and improve hypertension outcomes.