The state of hypertension care in 44 low- and middle-income countries: a cross-sectional study of individual-level nationally representative data from 1.1 million adults

Research output: Contribution to journalArticle


  • Pascal Geldsetzer
  • Jennifer Manne-Goehler
  • Maja-Emilia Marcus
  • Cara Ebert
  • Zhaxybay Zhumadilov
  • Chea Stanford Wesseh
  • Lindiwe Tsabedze
  • Adil Supiyev
  • Lela Sturua
  • Silver K Bahendeka
  • Abla M. Sibai
  • Sarah Quesnel-Crooks
  • Bolormaa Norov
  • Joseph Kibachio Mwangi
  • Omar Mwalim
  • Roy Wong McClure
  • Mary T Mayige
  • Joao S Martins
  • Nuno Lunet
  • Demetre Labadarios
  • Khem B Karki
  • Gibson B Kagaruki
  • Jutta M.A. Jorgensen
  • Nahla C. Hwalla
  • Dismand Houinato
  • Corine Houehanou
  • Mohamed Msaidie
  • David Guwatudde
  • Mongal Singh Gurung
  • Gladwell Gathecha
  • Maria Dorobantu
  • Albertino Damasceno
  • Pascal Bovet
  • Brice Wilfried Bicaba
  • Krishna K Aryal
  • Glennis Andall-Brereton
  • Kokou Agoudavi
  • Andrew Stokes
  • Till Bärnighausen
  • Rifat Atun
  • Sebastian Vollmer
  • Lindsay M Jaacks

Colleges, School and Institutes


Evidence from nationally representative studies in low- and middle-income countries (LMICs) on where patients are lost in the hypertension care continuum is sparse. This information, however, is essential for the effective design and targeting of health services interventions, and to assess progress in improving hypertension care. This study aimed to determine the cascade of hypertension care in 44 LMICs – and its variation between countries and population groups – by dividing the progression from need to successful treatment into discrete stages and measuring the losses at each stage.

We pooled individual-level population-based data collected between 2005 and 2016 from 44 LMICs. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or diastolic BP ≥90 mmHg or reporting use of medication for hypertension. Among those with hypertension, we calculated the proportion who had i) ever had their BP measured, ii) been diagnosed, iii) been treated, and iv) achieved control. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body mass index, smoking status, country, and region. We used linear regression to predict – separately for each cascade step – a country’s performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval.

1,100,507 participants were included of whom 192,441 (17.5%) had hypertension. 73.6% (95% CI, 72.9 – 74.3) of those with hypertension ever had their BP measured, 39.2% (95% CI, 38.2 – 40.3) were diagnosed, 29.9% (95% CI, 28.6 - 31.3) received treatment, and 10.3% (95% CI, 9.6 – 11.0) achieved control. Countries in Latin America and the Caribbean generally achieved the highest performance, while those in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not a current smoker were all positively associated with reaching each of the four steps of the care cascade.

This study provides critical evidence for the design and targeting of health policies and service interventions for hypertension in LMICs by detailing at what step and for whom there are gaps in the care process in each study country. In addition, we have identified countries that perform better than expected based on their economic development in a diversity of world regions, which can guide policy decisions. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades as constructed in this study could be used as an important tracer of effective universal health coverage.

Harvard McLennan Family Fund


Original languageEnglish
Pages (from-to)652-662
Number of pages11
JournalThe Lancet
Issue number10199
Early online date18 Jul 2019
Publication statusPublished - 24 Aug 2019