Care Cascades for Hypertension in Low-Income Settings: A Systematic Review and Meta-Analysis.

Objective: High blood pressure is the leading risk factor for cardiovascular disease. The hypertension care cascade (HCC) is increasingly being used to evaluate the effectiveness of interventions. This systematic review aims to examine HCC in low-income settings. Methods: The search strategy included articles published between January 2010 and April 2023. We excluded studies with incomplete HCC, on fragile patients or aged <18 years, reviews. We used the MOOSE guideline. Five researchers retrieved data on the survey year, country, population, HCC and diagnostic methods for hypertension. We used JBI Critical Appraisal Tools for quality assessment. Results: Ninety-five articles were analyzed. Average hypertension prevalence was 33% (95% CI: 31%-34%), lower in LICs than in LMICs (25% vs. 34%). The overall mean awareness of hypertension was 48% (95% CI: 45%-51%), its treatment was 35% (95% IC: 32%-38%) and its control 16% (95% CI: 14%-18%). In almost all steps, percentages were lower in LICs and in Sub-Saharan Africa. Conclusion: Trends in HCC vary between countries, with poorer performance in LICs. This review highlights the need for interventions tailored to low-income settings in order to improve hypertension care

Care Cascades for Hypertension in Low-Income Settings: A Systematic Review and Meta-Analysis

Objective: High blood pressure is the leading risk factor for cardiovascular disease. The hypertension care cascade (HCC) is increasingly being used to evaluate the effectiveness of interventions. This systematic review aims to examine HCC in low-income settings.Methods: The search strategy included articles published between January 2010 and April 2023. We excluded studies with incomplete HCC, on fragile patients or aged &lt;18 years, reviews. We used the MOOSE guideline. Five researchers retrieved data on the survey year, country, population, HCC and diagnostic methods for hypertension. We used JBI Critical Appraisal Tools for quality assessment.Results: Ninety-five articles were analyzed. Average hypertension prevalence was 33% (95% CI: 31%–34%), lower in LICs than in LMICs (25% vs. 34%). The overall mean awareness of hypertension was 48% (95% CI: 45%–51%), its treatment was 35% (95% IC: 32%–38%) and its control 16% (95% CI: 14%–18%). In almost all steps, percentages were lower in LICs and in Sub-Saharan Africa.Conclusion: Trends in HCC vary between countries, with poorer performance in LICs. This review highlights the need for interventions tailored to low-income settings in order to improve hypertension care

Layering and scaling up chronic non-communicable disease care on existing HIV care systems and acute care settings in Kenya: a cost and budget impact analysis

Like many countries in sub-Saharan Africa, Kenya is experiencing a rapid rise in the burden of non-communicable diseases (NCDs): NCDs now contribute to over 50% of inpatient admissions and 40% of hospital deaths in the country. The Academic Model Providing Access to Healthcare (AMPATH) Chronic Disease Management (CDM) programme builds on lessons and capacity of HIV care to deliver chronic NCD care layered into both HIV and primary care platforms to over 24,000 patients across 69 health facilities in western Kenya. We conducted a cost and budget impact analysis of scaling up the AMPATH CDM programme in western Kenya using the International Society for Pharmacoeconomics and Outcomes Research guidelines.; Costs of the CDM programme for the health system were measured retrospectively for 69 AMPATH clinics from 2014 to 2018 using programmatic records and clinic schedules to assign per clinic monthly costs. We quantified the additional costs to provide NCD care above those associated with existing HIV or acute care services, including clinician, staff, training, travel and equipment costs, but do not include drugs or consumables as they would be paid by the patient. We projected the budget impact of increasing CDM coverage to 50% of the eligible population from 2021 to 2025, and compared it with the county budgets from 2019.; The per visit cost of providing CDM care was $10.42 (SD$2.26), with costs at facilities added to HIV clinics $1.00 (95$2:11 to $0.11) lower than at primary care facilities. The budget impact of adding 26,765 patients from 2021 to 2025 to the CDM programme was 3,088,928 under constant percent growth, and 3,451,732 under steady-state enrolment. Scaling up under the constant percent growth scenario resulted in 12% cost savings in the budget impact. The county programmatic CDM cost in 2025 was <1% of the county healthcare budgets from 2019.; The budget impact of scaling up AMPATH's CDM programme will be driven by annual growth scenarios, and facility/provider mix. By leveraging task shifting, referral systems and partnering with public and non-profit clinics without NCD services, AMPATH's CDM programme can provide critical NCD care to new, rural populations with minimal financial impact

Care cascades for hypertension and diabetes: Cross-sectional evaluation of rural districts in Tanzania

Noncommunicable diseases (NCDs), especially hypertension and diabetes, are rapidly rising in sub-Saharan Africa, necessitating health systems transformations. In Tanzania, current policies aim to improve control of hypertension and diabetes, but information is still needed to assess the gaps in treatment.; We conducted a cross-sectional household survey of 784 adults in two districts in Tanzania from December 2020 to January 2021, capturing the cascade-of-care for hypertension and diabetes. The ages of the respondents ranged from 18 to 89 years. Of those screened positive for these conditions, we measured the proportion in each step of the cascades: awareness, care engagement, treatment, and control. We conducted multivariable logistic regression analyses for all four steps along the hypertension care cascade with the independent variables of social health protection schemes, and prior diagnosis of comorbid diabetes, and demographic information. In our sample, of the 771 who had their blood pressure measured, 41% (95% confidence interval (CI): 38% to 44%) were screened positive for hypertension, and of the 707 who had their blood sugar measured, 6% (95% CI: 4% to 8%) were screened positive for diabetes. Of those with hypertension, 43% (95% CI: 38% to 49%) had a prior diagnosis, 25% (95% CI: 21% to 31%) were engaged in care, 21% (95% CI: 3% to 25%) were on treatment, and 11% (95% CI: 8% to 15%) were controlled. Of the 42 respondents with diabetes, 80% (95% CI: 69% to 93%) had a prior diagnosis. The diabetes care cascade had much less drop-off, so 66% of those with diabetes (95% CI: 52% to 82%) were engaged in care and on treatment, and 48% (95% CI: 32% to 63%) had their diabetes controlled at the point of testing. Healthcare fee exemptions were independently associated with higher odds of being previously diagnosed (OR 5.81; 95% CI [1.98 to 17.10] p < 0.005), engaged in care (OR 4.71; 95% CI [1.59 to 13.90] p 0.005), and retained in treatment (OR 2.93; 95% CI [1.03 to 8.35] p < 0.05). Prior diagnosis of comorbid diabetes was highly associated with higher odds of being engaged in care for hypertension (OR 3.26; 95% CI [1.39 to 7.63] p < 0.005). The two primary limitations of this study were reliance on screening at a single time point only of people available at the village at the time of the sample and dependence on self-report for to inform the three cascade steps of prior diagnosis, healthcare visits for engagement in care, and treatment use.; The high burden of hypertension and low levels of control in our study underscores the importance of improving the awareness and treatment of hypertension. The differences in the care cascades for hypertension and diabetes demonstrates that chronic NCD treatment is possible in this setting, but efforts will be needed across the entire care cascade to improve hypertension control

Investigating sustainability challenges for the National Health Insurance Fund in Tanzania: a modelling approach

Objective This study aimed to model the long-term cost associated with expanding public health insurance coverage in Tanzania.Design, setting and participants We analysed the 2016 claims of 2 923 524 beneficiaries of the National Health Insurance Fund in Tanzania. The analysis focused on determining the average cost per beneficiary across 5-year age groups separated by gender, and grouped by broad health condition categories. We then modelled three different insurance coverage scenarios from 2020 to 2050 and we estimated the associated costs.Outcome measures Average cost per beneficiary and the projected financing requirements, projected from 2020 to 2050.Results The analysis revealed that the average per beneficiary cost for insurance claims was $38.58. Among males over 75 years, the average insurance claims costs were highest, amounting to$125. The total estimated annual cost of claims in 2020 was $151 million. Under the status quo coverage scenario, total claims were projected to increase to$415 million by 2050. Increasing coverage from 7% to 50% would result in an additional financing requirement of $2.27 billion. If coverage would increase by 10$2.84 billion.Conclusion This study highlights the critical importance of assessing the long-term financial viability of health insurance schemes aimed to cover large segments of the population in low-income countries. The findings demonstrate that even without expansion of coverage, financing requirements for insurance will more than triple by 2050. Furthermore, increasing coverage is likely to substantially escalate the cost of claims, potentially requiring significant government or external contributions to finance these additional costs. Policymakers and stakeholders should carefully evaluate the sustainability of insurance schemes to ensure adequate financial support for expanding coverage and improving healthcare access in low-income settings

Care cascade number of events in each stage of the care cascade.

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Inclusivity in global research checklist.

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Diabetes care cascade by social health protection schemes.

This shows the proportion of those who screened positive for diabetes in the farthest point along the diabetes care cascade at the point of measurement, disaggregated by social health protection status. (TIF)</p

Population-adjusted prevalance and care cascade for hypertension and diabetes.

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Hypertension care cascade by social health protection schemes.

This shows the proportion of those who screened positive for hypertension in the farthest point along the hypertension care cascade at the point of measurement, disaggregated by social health protection status. (TIF)</p