Innovations for effective implementation of guideline-based hypertension care in low-income and middle-income countries
Authors: Nitish Naik, Kavita Singh
Journal: The Lancet Global Health (2021)

Hypertension is the leading preventable cause of death and disability worldwide, accounting for 19·2% (10·8 million) of all deaths globally and 16·4% (2 million) of all deaths in low-income and middle-income countries.1Institute for Health Metrics and EvaluationGBD compare data visualization.http://vizhub.healthdata.org/gbd-compareDate: 2020Date accessed: February 12, 2021Google Scholar Hypertension is easy to diagnose, treat, and control, yet suboptimal screening and inadequate therapy has resulted in an increased number of patients with uncontrolled disease despite numerous advances over the past two decades. Increasing awareness, treatment, and control of hypertension is predicated on the accessibility and responsiveness of the health system to the needs of its population. Vertically aligned health programmes and a persistent shortage of trained physicians along with their disproportionate concentration in urban as opposed to rural areas have hampered routine periodic screening for non-communicable diseases in most low-income and middle-income countries. Effective hypertension control is thus multifactorial and requires a recalibration of the health system.2Vedanthan R Bernabe-Ortiz A Herasme OI et al.Innovative Approaches to hypertension control in low- and middle-income countries.Cardiol Clin. 2017; 35: 99-115Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar The COBRA-BPS study provides useful information on the effectiveness of a complex intervention programme led by community health workers in combating hypertension in rural areas.3Jafar TH Gandhi M de Silva HA et al.A Community-based intervention for managing hypertension in rural south Asia.N Engl J Med. 2020; 382: 717-726Crossref PubMed Scopus (36) Google Scholar In this cluster-randomised trial among 30 communities in Bangladesh, Pakistan, and Sri Lanka, a multicomponent hypertension management programme was evaluated for the budget that is required to scale up the programme and its cost-effectiveness.4Finkelstein EA Krishnan A Naheed A et al.Budget impact and cost-effectiveness analyses of the COBRA-BPS multicomponent hypertension management programme in rural communities in Bangladesh, Pakistan, and Sri Lanka.Lancet Glob Health. 2021; (published online March 19.)https://doi.org/10.1016/S2214-109X(21)00033-4Summary Full Text Full Text PDF PubMed Google Scholar The intervention was locally adapted, with targeted education, training of providers, regular blood pressure monitoring and referral, and a financing model to support additional service provision by community health workers. From the health system (public payer) perspective, the investigators found the first-year costs per participant to be US$10·65 for Bangladesh, $10·25 for Pakistan, and $6·42 for Sri Lanka, and recurrent costs per participant ranged from $5·70 (Pakistan) to $6·52 (Bangladesh). Incremental cost-effectiveness ratios ranged from $2270 (in Pakistan) to $4080 (in Sri Lanka) per cardiovascular disease-associated disability-adjusted life-year averted. Community health workers have traditionally been involved in the delivery of maternal and child health services in most low-income and middle-income countries as well as in HIV/AIDS programmes. Task sharing for hypertension control by community health workers offers a cost-effective way of addressing the community burden of hypertension. A 2019 meta-analysis showed a significant reduction in blood pressure when hypertension care was provided by non-physician health-care workers.5Anand TN Joseph LM Geetha AV Prabhakaran D Jeemon P Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e761-e771Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar The feasibility and success of a programme delivered by community health workers does pose several potential challenges, however.6Heller DJ Kumar A Kishore SP Horowitz CR Joshi R Vedanthan R Assessment of barriers and facilitators to the delivery of care for noncommunicable diseases by nonphysician health workers in low- and middle-income countries: a systematic review and qualitative analysis.JAMA Netw Open. 2019; 2e1916545Crossref PubMed Scopus (11) Google Scholar The effectiveness of the intervention is highly dependent on many health system factors such as availability, funding, and retention of an appropriately sized team of community health workers; adequate training, supervision, and monitoring of community health workers; the development of context-specific protocols for screening, diagnosing, referring, and treating patients; availability and access to affordable medicines; and clear career pathways for the community health workers. Many community health workers are often already overloaded with multiple responsibilities and are poorly remunerated, leading to poor motivation and job attrition. Designing a programme that is culturally and socially acceptable is a crucial factor that drives the success of the task-sharing strategy; for instance, many community health workers are women, and gender barriers in some communities might impair the effective rollout of a programme led by community health workers. Compared with the enormous effort spent on research to identify cost-effective treatments in clinical trials, there have been few efforts to integrate new strategies in routine clinical practice. The study by Finkelstein and colleagues4Finkelstein EA Krishnan A Naheed A et al.Budget impact and cost-effectiveness analyses of the COBRA-BPS multicomponent hypertension management programme in rural communities in Bangladesh, Pakistan, and Sri Lanka.Lancet Glob Health. 2021; (published online March 19.)https://doi.org/10.1016/S2214-109X(21)00033-4Summary Full Text Full Text PDF PubMed Google Scholar fills an important gap in informing health-care professionals and governments on how to improve hypertension care in rural communities. Progressively more rigorous methods have been used to generate evidence on the cost-effectiveness of interventions for hypertension control. Trial-based cost-effectiveness analyses along with budget impact analyses, as used by Finkelstein and colleagues,4Finkelstein EA Krishnan A Naheed A et al.Budget impact and cost-effectiveness analyses of the COBRA-BPS multicomponent hypertension management programme in rural communities in Bangladesh, Pakistan, and Sri Lanka.Lancet Glob Health. 2021; (published online March 19.)https://doi.org/10.1016/S2214-109X(21)00033-4Summary Full Text Full Text PDF PubMed Google Scholar generally provide a more robust estimate of cost-effectiveness than decision-based models.7Singh K Chandrasekaran AM Bhaumik S et al.Cost-effectiveness of interventions to control cardiovascular diseases and diabetes mellitus in South Asia: a systematic review.BMJ Open. 2018; 8e017809Crossref PubMed Google Scholar Despite the remarkably low per-participant cost reported in the trial,4Finkelstein EA Krishnan A Naheed A et al.Budget impact and cost-effectiveness analyses of the COBRA-BPS multicomponent hypertension management programme in rural communities in Bangladesh, Pakistan, and Sri Lanka.Lancet Glob Health. 2021; (published online March 19.)https://doi.org/10.1016/S2214-109X(21)00033-4Summary Full Text Full Text PDF PubMed Google Scholar expanding the COBRA programme could require a considerable increase in the health-care budget by at least 20–30% across the three countries. An increase in the out-of-pocket expenditure for pharmacotherapy for hypertension could also affect the willingness to seek and continue care. It is, therefore, important to understand how the COBRA-BPS intervention is valued from the patients, service providers, and societal perspectives in public and private facilities. With the increased implementation of health insurance models by governments in south Asia, further economic data will help to examine how different payers value interventions led by community health workers. Relative to overall budgets and estimated gains, there are other cost-effective strategies to manage hypertension.8Kostova D Spencer G Moran AE et al.The cost-effectiveness of hypertension management in low-income and middle-income countries: a review.BMJ Glob Health. 2020; 5e002213Crossref PubMed Scopus (7) Google Scholar However, despite all the implementation challenges and available cost-effectiveness evidence, task sharing among physicians and health workers should be viewed as an essential and key element for hypertension control in low-income and middle-income countries. The risk is as Toni Morrison said in her epic novel Song of Solomon: “If we don't create the future, the present extends itself”. We declare no competing interests. Budget impact and cost-effectiveness analyses of the COBRA-BPS multicomponent hypertension management programme in rural communities in Bangladesh, Pakistan, and Sri LankaThe low cost of scale-up and the cost-effectiveness of COBRA-BPS suggest that this programme is a viable strategy for responding to the growing cardiovascular disease epidemic in rural communities in low-income and middle-income countries where community health workers are present, and that it should qualify as a priority intervention across rural settings in south Asia and in other countries with similar demographics and health systems to those examined in this study. Full-Text PDF Open Access