Majida, 58, a Syrian patient at MSF’s non-communicable diseases (NCDs) project in Irbid governorate, northern Jordan, close to the Syrian borders, has her blood pressure ochecked by an MSF nurse in one of the two NCDs clinics in Irbid
Report |

Under Pressure: Strategies to improve access to antihypertensive medicines in low- and middle-income countries

Report cover image
Photograph by Maya Abu Ata

Background

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. 

Hypertension treatment

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.

Additional resources

Presentation on global sources and prices of anti-hypertensive medicines with a focus on single-pill combinations.

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:  

  • Reduce the pill burden for patients and improve adherence 
  • Make it simpler for healthcare workers to follow a simplified step-by-step approach to treatment 
  • Benefit health systems by simplifying forecasting, procurement and supply chain management 

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.  

Testimony
Hypertension patient Pambeyi MbeurePhotograph by Gloria Ganyani

Pambeyi Mbeure is from Chipinge, Zimbabwe.
He is HIV positive and he is also diabetic and has hypertension. Pambeyi started taking antiretroviral therapy (ART) in 2008 and was diagnosed with hypertension in August 2016 and with diabetes the following year.
“I have to take eleven tablets altogether every day which is just so exhausting, It's too much. I wish I could take two tablets at most (for hypertension) or even just one tablet, like we do for HIV,” Pambeyi says. 
 

The report has the following major findings:  

  • Generic hypertension medicine prices vary substantially across LMICs, with medicines in some countries costing 40 times more than the estimated cost-based generic price 
  • Despite being recommended as the standard, SPCs are often unavailable or unaffordable to patients 
  • However, in some settings SPCs are already less costly to use than the sum of the price of their equivalent SAPs 
  • At current prices, many LMIC governments cannot offer affordable and safe essential medical treatment to people living with hypertension 

What needs to be done 

  • National guidelines need to be revised according to WHO 2021 guidance with simplified algorithms including SPCs 
  • SPCs need to be prioritised for inclusion in national essential medicines lists  
  • Forecasting and budgeting for hypertension medicines by donors and ministries of health should be based on WHO-approved hypertension algorithms  
  • Government procurement strategies should promote the transparency of antihypertensive medicine prices and incentivise medicine pricing exercises using the estimated cost-based generic price to inform negotiations
Hypertension - single pill combination anti-hypersensitive medicines MSF
Estimated cost-based generic pricing data suggests that single-pill combinations are not more expensive to make. MSF
Hypertension - estimated cost based generic price comparison MSF
It is disheartening that although one in five people in Eswatini has hypertension, accessing treatment has been a major challenge [...] we need to find ways of scaling up access to these single-pill combinations. MSF