The economic burden of treating uncomplicated hypertension in Sub-Saharan Africa: a systematic literature review

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Application of decision analytic modelling to cardiovascular disease prevention in Sub-Saharan Africa: a systematic review

BACKGROUND

This systematic review sought to examine the application of decision analytic models (DAMs) to evaluate cardiovascular disease (CVD) prevention interventions in sub-Saharan Africa (SSA), a region that has experienced an increasing CVD burden in the last two decades.

METHODS

We searched seven databases and identified model-based economic evaluations of interventions targeting CVD prevention among adult populations in SSA. All articles were screened by two reviewers, data was extracted, and narrative synthesis was performed. Quality assessment was performed using the Philips checklist.

RESULTS

The review included 27 articles from eight SSA countries. The majority of the studies evaluated interventions for primary CVD prevention, with primordial prevention interventions being the least evaluated. Markov models were the most commonly used modelling method. Seven studies incorporated equity dimensions in the modelling, which were assessed mainly through subgroup analysis. The mean quality score of the papers was 68.9% and most studies reported data challenges while only three studies conducted model validation.

CONCLUSIONS

The review finds few studies modelling the impact of interventions targeting primordial prevention and those evaluating equitable strategies for improving access to CVD prevention. There is a need for increased transparency in model building, validation and documentation.

Discrete choice modelling of hypertension patients' preferences for attributes of a public medical facility in Ibadan, Nigeria

BACKGROUND

Not much is known about hypertension patients' preferences for attributes of public medical facilities in Nigeria and how these preferences influence their choices of medical facilities for treatment. An understanding of what these patients want especially in terms of service delivery could contribute to improved hypertension control.

OBJECTIVE

This study aimed to determine hypertension patients' preferences for attributes of a public medical facility in Ibadan, Nigeria.

METHODS

A Discrete Choice Experiment (DCE) that utilized three hypothetical medical facilities was used for the study. A simple random sample (SRS) of 150 eligible hypertension patients was selected from a secondary medical facility in Ibadan, Nigeria. An efficient D-optimal choice design was adopted and used in generating nine hypothetical choice sets for the experiment. Each patient was expected to study the nine sets carefully and choose an option from each of the sets. The first choice set was repeated as the tenth set to examine respondents' consistency. The DCE questionnaires were administered using a one-to-one interview method. A mixed logit regression modeling technique was used to obtain parameter and Willingness to Pay (WTP) estimates.

RESULTS

The patients preferred medical facilities with waiting time before consultation with medical doctors to be between thirty minutes and one hour. The attribute level ''a lot of information'' was the most preferred. The patients were unwilling to pay for the "little or no drugs and diagnostic equipment" attribute level. A negative and significant coefficient for cost indicated that higher out-of-pocket costs negatively affected hypertension patients' choice of a public medical facility.

CONCLUSION

Hypertension patients attending a public medical facility in Ibadan, Nigeria preferred a facility with access to comprehensive information about their health in addition to reasonable waiting times, availability of a lot of drugs and diagnostic equipment, and reduced out-of-pocket costs. Provision of healthcare services that align with these preferences could enhance patient satisfaction thus contributing to improved hypertension control.

The accuracy of anthropometric indices in detecting hypertension in Sudanese adults: a cross-sectional study

BACKGROUND

Hypertension is an increasing health problem; hence, efforts have been made to promote the disease's early detection and modify prognoses. We aim to evaluate the accuracy of body mass index (BMI), waist circumference (WC), and waist-height ratio (WHtR) in detecting hypertension among adults in Northern Sudan.

METHODS

Adults were recruited for a multi-stage sampling survey in Northern Sudan. Sociodemographic and anthropometric index (BMI, WC, and WHtR) information were collected. A receiver operating characteristic (ROC) curve with its area under the curve (AUC) was obtained, and a multivariate binary analysis was performed.

RESULTS

Of the 301 included adults, 113 (37.5%) were females and 188 (62.5%) were males. The median (interquartile range, IQR) age was 45.0 (32.0‒59.0) years. The median (IQR) of BMI, WC, and WHtR was 25.6 (21.9‒29.7) kg/m2, 83.0 (73.0‒94.8) cm, and 0.51 (0.43‒0.58), respectively; these values were significantly higher in adults with hypertension compared with adults without hypertension. A total of 166 (55.1%) adults had hypertension. BMI (AUC = 0.69 at the cutoff 22.5 kg/m2, sensitivity = 0.89, specificity = 0.53, YI = 0.35) and WHtR for both males and females (AUC = 0.68 at the cutoff 0.48, sensitivity = 0.75, specificity = 0.60, YI = 0.35) were more accurate than WC (AUC = 0.66 at the cutoff 77.5 cm, sensitivity = 0. 77, specificity = 0.56, YI = 0.33). The multivariate binary analysis revealed that being female (adjusted odds ratio [AOR] = 2.23, 95.0% CI = 1.25‒3.97), having increased age (AOR = 1.04, 95% CI = 1.02‒1.05), and having a higher BMI (AOR = 1.10, 95% CI = 1.04‒1.16) were associated with hypertension.

CONCLUSION

BMI, WC, and WHtR showed moderate predictive power, suggesting that these indices have a limited role in diagnosing hypertension at the individual level and are more appropriate for population screening than for individual diagnosis. BMI performs better than WC in terms of hypertension detection.

The economic burden of type 2 diabetes on the public healthcare system in Kenya: a cost of illness study

BACKGROUND

The burden of chronic non-communicable diseases (NCDs) is a growing public health concern. The availability of cost-of-illness data, particularly public healthcare costs for NCDs, is limited in Sub-Saharan Africa (SSA), yet such data evidence is needed for policy action.

OBJECTIVE

The objective of this study was to estimate the economic burden of type 2 diabetes (T2D) on Kenya's public healthcare system in 2021 and project costs for 2045.

METHODS

This was a cost-of-illness study using the prevalence-based bottom-up costing approach to estimate the economic burden of T2D in the year 2021. We further conducted projections on the estimated costs for the year 2045. The costs were estimated corresponding to the care, treatment, and management of diabetes and some diabetes complications based on the primary data collected from six healthcare facilities in Nairobi and secondary costing data from previous costing studies in low and middle-income countries (LMICs). The data capture and costing analysis were done in Microsoft Excel 16, and sensitivity analysis was conducted on all the parameters to estimate the cost changes.

RESULTS

The total cost of managing T2D for the healthcare system in Kenya was estimated to be US$ 635 million (KES 74,521 million) in 2021. This was an increase of US$ 2 million (KES 197 million) considering the screening costs of undiagnosed T2D in the country. The major cost driver representing 59% of the overall costs was attributed to T2D complications, with nephropathy having the highest estimated costs of care and management (US$ 332 million (KES 36, 457 million). The total cost for T2D was projected to rise to US$ 1.6 billion (KES 177 billion) in 2045.

CONCLUSION

This study shows that T2D imposes a huge burden on Kenya's healthcare system. There is a need for government and societal action to develop and implement policies that prevent T2D, and appropriately plan care for those diagnosed with T2D.

The financial burden of noncommunicable diseases from out-of-pocket expenditure in sub-Saharan Africa: a scoping review

The growing financial burden of noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA) hinders the attainment of the sustainable development goals. However, there has been no updated synthesis of evidence in this regard. Therefore, our study summarizes the current evidence in the literature and identifies the gaps. We systematically search relevant databases (PubMed, Scopus, ProQuest) between 2015 and 2023, focusing on empirical studies on NCDs and their financial burden indicators, namely, catastrophic health expenditure (CHE), impoverishment, coping strategies, crowding-out effects and unmet needs for financial reasons (UNFRs) in SSA. We examined the distribution of the indicators, their magnitudes, methodological approaches and the depth of analysis. The 71 included studies mostly came from single-country (n = 64), facility-based (n = 52) research in low-income (n = 22), lower-middle-income (n = 47) and upper-middle-income (n = 10) countries in SSA. Approximately 50% of the countries lacked studies (n = 25), with 46% coming from West Africa. Cancer, cardiovascular disease (CVD) and diabetes were the most commonly studied NCDs, with cancer and CVD causing the most financial burden. The review revealed methodological deficiencies related to lack of depth, equity analysis and robustness. CHE was high (up to 95.2%) in lower-middle-income countries but low in low-income and upper-middle-income countries. UNFR was almost 100% in both low-income and lower-middle-income countries. The use of extreme coping strategies was most common in low-income countries. There are no studies on crowding-out effect and pandemic-related UNFR. This study underscores the importance of expanded research that refines the methodological estimation of the financial burden of NCDs in SSA for equity implications and policy recommendations.

Managing hypertension in rural Gambia and Kenya: Protocol for a qualitative study exploring the experiences of patients, health care workers, and decision-makers

Background

Hypertension is the single leading risk factor for premature death in Sub-Saharan Africa (SSA). Prevalence is high, but awareness, treatment, and control are low. Community-centred interventions show promise for effective hypertension management, but embedding such interventions sustainably requires a good understanding of the wider context within which they are being introduced. This study aims to conduct a systematic health system assessment exploring the micro (patients/carers), meso (health care workers and facilities), and macro (broader system) contexts in rural Gambia and Kenya.

Methods

This study will utilise various qualitative approaches. We will conduct (i) focus group discussions with people living with hypertensive to map a 'typical' patient journey through health systems, and (ii) in-depth interviews with patients and family carers, health care workers, decision-makers, and NCD partners to explore their experiences of managing hypertension and assess the capacity and readiness of the health systems to strengthen hypertension management. We will also review national guidelines and policy documents to map the organisation of services and guidance on hypertension management. We will use thematic analysis to analyse data, guided by the cumulative complexity model, and theories of organisational readiness and dissemination of innovations.

Expected findings

This study will describe the current context for the management of hypertension from the perspective of those involved in seeking (patients), delivering (health care workers) and overseeing (decision-makers) health services in rural Gambia and Kenya. It will juxtapose what should be happening according to health system guidance and what is happening in practice, drawing on the experiences of study participants. It will outline the various barriers to and facilitators of hypertension management, as perceived by patients, providers, and decision-makers, and the conditions that would need to be in place for effective and sustainable implementation of a community-centred intervention to improve the management of hypertension in rural settings.

Projected burden and distribution of elevated blood pressure levels and its consequence among adolescents in sub-Saharan Africa

Background

There is minimal data on the number of adolescents in sub-Saharan Africa (SSA) with elevated blood pressure (BP) at increased risk of future cardiovascular events. Combining country-specific population data with data derived from two previously conducted meta-analyses (one African-specific, one based on international cohorts), we sought to address this knowledge deficit.

Methods

We used meta-analysis data from 37 926 adolescents participating in 36 contemporary SSA studies to generate sex-specific proportions of adolescents aged 10-14 and 15-19 years with elevated BP. The estimates were applied to the 2021 World Bank population data for each country in SSA. We then applied the rate of cardiovascular events attributable to elevated BP levels, derived from a meta-analysis of 17 observational, longitudinal cohort studies comprising 4.5 million young adults (non-African), to determine the excess number of cardiovascular events linked to hypertension among those aged 15-19 years transitioning to adulthood.

Results

The estimated prevalence of elevated BP among male and female adolescents aged 10-14 years living in SSA was 7.2% (95% confidence interval (CI) = 4.9-9.9) and 6.9% (95% CI = 4.7-9.5), respectively, which increased to 13.0% (95% CI = 10.6-15.6) and 12.5% (95% CI = 10.4-15.3) among male and female adolescents aged 15-19 years, respectively. Consequently, we estimate that 13.6/138.0 million (95% CI = 10.4-17.3) male and 12.9/135.7 million (95% CI = 9.83-16.3) female adolescents living in SSA have elevated BP. Among the estimated 16.1 million adolescents aged 15-19 years with elevated BP approaching adulthood, the projected excess in cardiovascular events attributable to hypertension (vs normotension) is 201 000 (95% CI = 115 000-322 000) to 503 000 (95% CI = 286 000-805 000) over the next 10-25 years.

Conclusions

Based on the best available data, we estimate that 26.5 million adolescents living in SSA have elevated BP. If left undetected and untreated among those approaching adulthood (those aged 15-19 years), they will experience >0.5 million excess cardiovascular events associated with persistently elevated BP within the next 25 years.

Registration

PROSPERO: CRD42022297948.

Modifiable risk factors of inequalities in hypertension: analysis of 100 million health checkups recipients

Inequalities in health behaviors are thought to contribute to inequalities in hypertension. This study examined the extent to which modifiable mediating factors explain income inequalities in hypertension. This repeated cross-sectional study used data from National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) from 2009 to 2015. Those aged between 40 and 74 were enrollees in the Specific Health Checkups. Hypertension was defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90, or the use of antihypertensive medication. The mediating effects of exercise, obesity, smoking, and alcohol drinking on the association between income, as an indicator of SES, and hypertension were determined by the Karlson-Holm-Breen (KHB) method. The mean age of the 68,684,025 men and 59,118,221 women was 54.7 (SD = 9.6) and 56.7 (SD = 10.0) years, respectively. Prevalence of hypertension was higher in the lowest income group (48.6% for men, 40.2% for women) than in the highest income group (33.3% for men, 21.5% for women). Inequalities tended to increase over time. Inequalities were larger among those who did not use antihypertensive medication. Modifiable risks explained 10.6% of the association between income and hypertension for men and 15.1% for women. In men, drinking and obesity explained 8.8% and 5.5% of the inequalities in hypertension, respectively. In women, obesity explained 18.8%. Exercise increased the proportion mediated over time. Smoking explained 5.5% among women taking antihypertensive medication. There were health inequalities in hypertension among Japanese adults, and the modifiable risk factors partially explained the inequalities.

Human and financial resource needs for universal access to WHO-PEN interventions for diabetes and hypertension care in Eswatini: results from a time-and-motion and bottom-up costing study

BACKGROUND

Eswatini faces persistent challenges in providing care for diabetes and hypertension, exacerbated by a shortage of healthcare workers. The implementation of WHO-PEN interventions aimed to address these issues, yet their effects on healthcare worker time requirements and associated costs remain unclear.

METHODS

This study employed a time-and-motion analysis and a bottom-up cost assessment to quantify the human and financial resources required for scaling up WHO-PEN interventions nationally in Eswatini for all estimated diabetic and hypertensive patients.

RESULTS

Findings reveal that healthcare workers in intervention-arm clinics reported longer workday durations compared to those in control-arm clinics, yet spent less time per patient while seeing more patients. The implementation of WHO-PEN interventions increased the workload on healthcare workers but also led to a notable increase in patient care utilization. Furthermore, a morning peak in patient visits was identified, suggesting potential opportunities for optimizing patient flow. Notably, scaling up care provision nationally with WHO-PEN interventions proved to be more cost saving than expanding standard-of-care treatment.

CONCLUSION

WHO-PEN interventions hold promise in improving access to diabetes and hypertension care in Eswatini while offering an efficient solution. However, addressing challenges in healthcare workforce creation and retention is crucial for sustained effectiveness. Policy makers must consider all aspects of the WHO-PEN intervention for informed decision-making. Trial registration US Clinical Trials Registry. NCT04183413. Trial registration date: December 3, 2019. https://ichgcp.net/clinical-trials-registry/NCT04183413.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Productivity-adjusted life-years and correlates of uncontrolled hypertension at two health facilities in Zambia

BACKGROUND

Hypertension has in the recent past surfaced as one of the conditions that has a significant impact on workforce productivity in emerging economies. Zambia is no different and has in the recent past recorded increasing cases. Despite the impact of hypertension being of great importance in regards to productivity, we have scarcity of data and studies on hypertension-related Productivity-Adjusted Life-Years (PALYs) in Zambia and Africa at large. This study assessed the impact of hypertension on PALYs lost and socioeconomic factors associated with nonadherence to antihypertensive medication (NATAM).

METHODS

This was a cross-sectional study of 198 participants from Livingstone University Teaching Hospital and Maramba Clinic situated in Livingstone, Zambia. Structured questionnaires were used to collect data. Productivity index multiplied by years lived was used to calculate PALYs and descriptive statistics were used to summarize sociodemographic, clinical and economic variables. Multivariable logistic regression was used to determine factors associated with NATAM.

RESULTS

The participants had a median age (interquartile range (IQR)) of 49 years (41, 59) and 60.1% (n = 119) were females while 39.9% (n = 79) were male. Our estimated PALYs lost per person due to hypertension were 0.2 (IQR 0.0, 2.7). Cumulative PALYs value lost due to the burden of hypertension was estimated to be at $871,239.58 in gross domestic product (GDP). The prevalence of NATAM was 48% (n = 95). The factors that were significantly associated with NATAM were age (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.90, 0.98), female sex (OR 2.52; 95%CI 1.18, 5.40), self-employment (OR 2.57; 95%CI 1.02, 6.45) and absenteeism from work (OR 3.60; 95%CI 1.16, 11.22).

CONCLUSIONS

Findings in our study highlight a high economic loss of PALYs due to hypertension with a potential to impact GDP negatively. We also found that NATAM reduced productivity and income among individuals of working age further impacting PALYs lost due to hypertension. The factors associated with NATAM were age, sex, employment status and absenteeism from work. This study underscores the need for interventions targeting young people, females, self-employed individuals, and absentees at work to improve adherence to antihypertensive drugs in order to reduce PALYs lost due to hypertension.

Trends in the prevalence and economic burden of hypertension and its socioeconomic disparities in rural southwestern China: two repeated cross-sectional studies

OBJECTIVES

This study aimed to analyse trends in the prevalence and economic burden of hypertension and its socioeconomic disparities in rural southwestern China.

DESIGN

Two repeated cross-sectional studies were conducted to collect interview and health examination data among individuals aged ≥35 years in rural Yunnan Province, China.

SETTING

Three rural areas of Yunnan, China.

PARTICIPANTS

We invited 8187 consenting participants in 2010-2011 and 7572 consenting participants in 2020-2021 to undergo interviews and health examinations.

RESULTS

The standardised prevalence of hypertension significantly increased from 26.1% in 2011 to 40.4% in 2021 (p<0.01), and the per capita direct, indirect and disease economic burdens increased from US$1323, US$46 and US$1369 to US$2196, US$49 and US$2244, respectively. In addition to the indirect economic burden, the direct and disease economic burdens increased significantly. The prevalence of hypertension was higher in illiterate population, among participants with low annual household income per capita, and participants with good access to medical services than in their counterparts who had good education, high annual household income per capita and poor access to medical services (all p<0.05). Moreover, the prevalence of hypertension showed a downward trend with improvement in socioeconomic position (SEP) (p<0.05). The per capita direct and disease economic burdens increased most in participants with low SEP, but the per capita indirect economic burden increased most in participants with upper-middle SEP.

CONCLUSIONS

The prevalence and economic burden of hypertension have visibly accelerated in rural Yunnan Province over the 10 years studied, and socioeconomic disparities have been found in the prevalence and economic burden of hypertension. These findings highlight that socioeconomic differentials should be tailored to address the timing of effective interventions for hypertension prevention and control and reduce the economic burden of hypertension in rural southwestern China.

Assessment of hypertension service availability in some primary health centres in Nigeria: a mixed-methods study

OBJECTIVE

Strengthening primary health centre (PHC) systems is a potentially effective strategy to reduce the burden of non-communicable diseases in Nigeria, a low/middle-income country with limited resources. The aim of this study was to assess hypertension service availability in some PHCs in Nigeria and seek recommendations that could facilitate improved services from PHC workers.

DESIGN

Explanatory sequential mixed-methods study.

SETTINGS

PHCs in the six geopolitical zones and Federal Capital City of Nigeria.

PARTICIPANTS

Eighteen PHC workers and 305 PHC facilities.

METHOD

Hypertension service availability and readiness were assessed in PHCs across Nigeria using a pro forma adapted from the WHO Service Readiness and Assessment tool. Eighteen workers in the PHCs were subsequently interviewed for in-depth exploration of hypertension service availability and readiness.

FINDINGS

Among the 305 health facilities assessed, 96 (31.5%) were in urban, 94 (30.8%) in semiurban and 115 (37.7%) in rural local government areas. Majority of the health facilities (43.0%) were manned by community extension workers. Only 1.6% and 19.7% of the health facilities had physicians and pharmacy technicians, respectively. About 22.3% of the providers had training in hypertension in the last 1 year. All the PHCs lacked adequate supply of essential antihypertensive medications. The identified deficiencies were less common in the urban PHCs compared with others. Qualitative analysis showed that the personnel, essential facilities and medicines required to provide hypertension services in the PHCs were inadequate. Suggested recommendations to successfully provide these services were provision of performance-based incentives; adequate staffing and training; supportive supervision of staff; provision of adequate equipment and essential medicines for hypertension management; provision of conducive environment for clients; and community engagement and participation.

CONCLUSION

Majority of the PHCs are currently not adequately equipped to provide hypertension services. Addressing identified gaps and using suggestions provided will guarantee successful provision of effective services.