Cardiovascular Diseases in Pakistan – Imagining a Post-Pandemic, Post-Conflict Future

Cardiovascular diseases (CVD) are rising in Pakistan. Situated at the crossroads of Central Asia, the Middle East, and South Asia, Pakistan is the fifth most populous country in the world. Over the last 30 years our country has seen economic/industrial growth, but regional conflicts, natural disasters, and limited government investment in health have stunted progress in health indicators. Compared with our neighbors to the east, Pakistanis have a lower average lifespan (men: 67 yrs, women: 69 yrs). Whereas infectious diseases remain endemic, our poorly resourced health systems are now grappling with the continuously rising and costly burden of non-communicable diseases, particularly CVD. According to the 2019 Global Burden of Disease study, the estimated age standardized incidence of CVD in Pakistan was 918.18/100,000 (Global: 684.33/100,000), and the age standardized death rate was 357.88/100,000 (Global: 239.85/100,000). ¹In the National Socioeconomic Registry Survey that included demographic, socioeconomic, education, health and asset profiling of 34 million households across Pakistan, cardiovascular diseases were self-reported by 18.9% participants.

For the foreseeable future this rising trend will continue as CVD risk factors are highly prevalent; age-adjusted comparative prevalence of diabetes is 30.8%; 37% of adults have hypertension; ~25% of adult males smoke; and high consanguinity rates (58% married to first or second cousins) likely contribute to clustering of genetic risk. Together, these factors will fuel a large rise in CVD burden as a predominantly young population enters middle age. This will pose major challenges as health spending remains low ($43 per person; government health expenditure = 1.2% of GDP), and globally Pakistan falls in the lowest decile for the Universal health coverage effectiveness index. ^{2, 3}Features of CVD specific to Pakistan include a high burden of rheumatic heart disease and early onset coronary artery disease.

Against this backdrop, Pakistan currently lacks a national strategy to monitor, prevent, and manage CVD in both rural and urban (37%) populations. Critical areas that need to be addressed include the following:

Data to monitor progress

At present CVDs do not comprehensively feature in any regular surveys, and estimates are based on sparse, outdated data. Howeverm recent efforts have included the Cardiac Registry of Pakistan (CROP) that monitors the quality of interventional procedures and management of acute coronary syndromes throughout the country. Additionally, vital registration, documentation of cause of death and regular community surveys need to be supported by the government. Regular monitoring would allow mapping of subnational prevalence and distribution across vulnerable populations.

Resources

A connected, competent professional workforce across the health system is necessary to manage the current burden of disease and alter the trajectory for the future. Pakistan has a doctor to population ratio of 1.09/1000 and a nurse/lady health visitor/midwife to population ratio of 0.59/1000. Currently, there are 1147 trained cardiologists who have been awarded cardiology fellowship through the College of Physicians and Surgeons Pakistan and 813 trainees who are enrolled in 47 approved training programs. Few cardiologists have returned after training in the UK or USA and less than a third of cardiologists (27%) are female.

Non-traditional models of care delivery including community healthcare workers (CHWs) (who are often women) have been instrumental in rolling out maternal health programs but can also be leveraged for CVD risk reduction at the community level. For example, a multicomponent intervention that included home visits by trained CHWs linked with existing public health infrastructure was effective in managing blood pressure compared with usual care (relative risk reduction 1.22; 95% CI 1.10–1.35) in Pakistan, Sri Lanka and Bangladesh. ⁴If further scaled, the CHW model would also improve access to care for women, a particular challenge in Pakistan.

Pakistan has 8.9 hospital beds/10,000 population and a public health care delivery network that is tiered with 6142 primary care centers, and 1282 hospitals. Intentional investment in managing cardiovascular disease has included the development of a network of cardiac care hospitals (9 satellite centers across the Sindh province with their flagship, the National Institute of Cardiovascular Diseases in Karachi). These centers provide cost-free care to all ST elevation myocardial infarction (STEMI) patients. In 2021, this network performed 16,958 primary PCIs for acute STEMI. Yet, nationally we are far from goal - there are approximately 130 cardiac catheterization labs in the country and of these only 36 offer 24/7 primary PCI.

Cost of care is often borne by the patient as most patients (~70%) choose to obtain care at private facilities. To protect against catastrophic health expenditure, the federal and provincial governments have introduced the Sehat Sahulat program and the Social Health Protection Initiative to cover inpatient care. Initial reports from the Khyber Pakhtunkhwa province show that cardiovascular care represent the highest number of claims. These initiatives ideally should evolve to cover outpatient visits, medications, and preventive primary care.

Research

A rise in CVD has not been accompanied by a commensurate increase in research. Clinical and basic science research are sparse, spearheaded by only a few institutions. Jafar et al through the Control of Blood Pressure and Risk Attenuation (COBRA) studies have demonstrated effective community level care delivery models. Saleheen and colleagues continue to study the genetic basis of early disease through the Pakistan Risk of Myocardial Infarction Study (PROMIS) and other linked cohorts. ^{4, 5} The PAK SEHAT (PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs) study is ongoing and aims to determine the prevalence and biologic correlates of early coronary artery disease.

Efforts to promote research and create a cadre of CVD research leaders have been led by academic institutions supported by external funders such as the Fogarty International Center, NIH, USA and the NIHR, UK. Sustainability of these initiatives requires Pakistan’s governmental and philanthropic sector matching, coupled with investment which is meager at present.

National Strategy

Figure 1 depicts multiple causes of CVD rise in Pakistan as well as proposed solutions. A multi-sector central command approach, guided by experts, data, community engagement, media messaging, and public-private partnerships comprised the backbone of the government’s successful COVID19 response and can be replicated and enhanced to combat CVD.

Figure 1.

Causes of and proposed solutions for cardiovascular disease in Pakistan.