The cost-effectiveness of hypertension management in low-income and middle-income countries: a review

Abstract

Hypertension in low-income and middle-income countries (LMICs) is largely undiagnosed and uncontrolled, representing an untapped opportunity for public health improvement. Implementation of hypertension control strategies in low-resource settings depends in large part on cost considerations. However, evidence on the cost-effectiveness of hypertension interventions in LMICs is varied across geographical, clinical and evaluation contexts. We conducted a comprehensive search for published economic evaluations of hypertension treatment programmes in LMICs. The search identified 71 articles assessing a wide range of hypertension intervention designs and cost components, of which 42 studies across 15 countries reported estimates of cost-effectiveness. Although comparability of results was limited due to heterogeneity in the interventions assessed, populations studied, costs and study quality score, most interventions that reported cost per averted disability-adjusted life-year (DALY) were cost-effective, with costs per averted DALY not exceeding national income thresholds. Programme elements that may reduce cost-effectiveness included screening for hypertension at younger ages, addressing prehypertension, or treating patients at lower cardiovascular disease risk. Cost-effectiveness analysis could provide the evidence base to guide the initiation and development of hypertension programmes.

Keywords: health economics; hypertension; review.

Figure 1

Summary diagram of the costs and cost-effectiveness literature search process. *Other sources searched include the Cochrane Collaboration Database of Systematic Reviews, the Tufts Cost-Effectiveness Analysis Registry, the UK’s National Institute for Health and Care Excellence (NICE) guidelines, the University of York Centre for Reviews and Dissemination and the Disease Control Priorities (3^rd Edition). These databases were hand searched using similar terms as the PubMed search strategy found in online supplementary appendix table A3.

Figure 2

Annual cost per treated hypertension patient in hypertension management programmes (2017 US$). Notes: Estimates from 21 studies. LLMICs: India, Kenya and Pakistan; UMICs: Argentina, Brazil, China, Malaysia, Mexico and South Africa. ‘Pharm only’ indicates interventions where pharmacotherapy is the only treatment element. ‘Pharm plus’ indicates combination programmes that incorporate other forms of treatment for hypertension in addition to medications. ‘Other’ indicates interventions that did not evaluate changes in pharmacological treatment. LMICs, low-income and middle-income countries; LLMICs, low-income and lower-middle-income countries; UMICs, upper-middle-income countries; US$, US dollars.

Figure 3

Range of monthly drug cost (2017 US$) by treatment type (minimum, median, and maximum values). Notes: Estimates from 23 studies reporting costs of medication treatment only. A2A, alpha-2 agonists; ACEI, ACE inhibitors; ARB, angiotensin-2 receptor blockers; BB, beta blockers; CAA, central acting antiadrenergics; CAI, central adrenergic inhibitors; CCB, calcium channel blockers; D, diuretics; US$, US dollars.

Figure 4

Cost per DALY averted, by CVD risk (in '000s 2017 US$). Notes: Estimates from six studies reporting risk-specific estimates across multiple CVD risk levels (Basu, Ha, Khonputsa, Ngalesoni, Praveen, Tolla). CVD, cardiovascular disease; DALY, disability-adjusted life year; US$, US dollars.