

Cardiovascular disease is the world’s biggest killer, representing 32% of all global deaths. Of these deaths, 85% are due to heart attack and stroke.
1.13 billion people have hypertension, also known as high blood pressure, a condition that is responsible for approximately half of all heart disease and strokes. The overwhelming majority of these patients live in low- and middle-income countries (LMICs).
Hypertension is a “silent killer” as most people with hypertension are not aware of their diagnosis. Globally only 23% of women and 18% of men with hypertension have their blood pressure controlled.
Traditionally, hypertension treatment has been initiated with monotherapy — that is, starting with a single agent pill (SAP, or one medicine per pill) and increasing the dose of the same medicine or adding a second medicine, based on blood pressure response.
However, the multiple steps and multiple medicines involved often result in a high pill burden for and poor adherence by patients.
The price of hypertension medicines is also a major challenge in many settings.
In July 2021 WHO launched new guidance for the treatment of hypertension, recommending the use of single-pill combinations (SPCs, or two or more medicines in one pill). SPCs are preferable to SAPs because they:
In MSF projects more than three-quarters of patients need two or more hypertension medicines. Introduction of SPCs into these projects, however, has been a challenge. The report “Under Pressure”, developed in collaboration with Resolve to Save Lives, helps us understand why this is the case, and identifies what WHO, donors, member states, civil society and the pharmaceutical industry need to do to improve access to SPCs for patients in MSF’s projects and beyond.
The report has the following major findings:
What needs to be done