Abstract
Background
Hypertension (HTN) is a leading modifiable risk factor for cardiovascular disease, yet diagnosis, treatment, and control are suboptimal in many low- and middle-income countries. The World Health Organization HEARTS program is a standardized approach to improve HTN management in primary care.
Objectives
The purpose of this study was to model the program costs and health benefits of scaling up the HEARTS program over 2025-2040 in 4 low- and middle-income countries with HEARTS programs: Bangladesh, Ethiopia, Nigeria, and the Philippines.
Methods
A cardiovascular disease simulation model estimated health benefits—averted deaths and disability—of increasing HEARTS HTN treatment coverage by 15 percentage points from 2025 to 2040 in the 4 countries. Program costs were obtained from the HEARTS programs including staff salaries, medications, diagnostics, and infrastructure in 2023 international dollars ($). Base and alternative cost scenarios projected HEARTS program budget impact, health benefits, cost-effectiveness over 2025 to 2040.
Results
By 2040, cost of scaling up HEARTS treatment coverage is projected to be $2.9 billion in Bangladesh, $1.7 billion in Nigeria, $0.9 billion in the Philippines, and $0.5 billion in Ethiopia. Across the 4 countries, cost per primary care user ranged from $3 to 16 and cost per patient treated ranged from $27 to 67. HEARTS scale-up can prevent more than 300,000 deaths by 2040: 120,000 in Bangladesh, 77,500 in Nigeria, 47,200 in Ethiopia, and 82,000 in the Philippines. Alternative scenarios assuming lower-cost components identified ways to improve HEARTS affordability and economic returns.
Conclusions
Scale-up of HEARTS HTN control package may provide increased health gains and economic benefits over time.
Key words: budget impact, cost, HEARTS, hypertension control, investment case, World Health Organization
Central Illustration
Hypertension (HTN) is the leading modifiable risk factor for cardiovascular disease (CVD) worldwide.1,2 Despite availability of low-cost antihypertensive medications, critical gaps in HTN control persist. Globally, only 2 in 5 HTN patients are treated, and one in every 5 have their blood pressure controlled (<140/90 mm Hg).2 In low- and middle-income countries (LMICs) in particular, where government health care resources are constrained, evidence on the value added by scaling up HTN services could help to justify country investments in HTN control programs.3
Evidence-based guidelines for scaling up HTN services are outlined in the World Health Organization (WHO)-HEARTS technical package.4 The HEARTS package aims to improve CVD outcomes by simplifying and standardizing the clinical approach to HTN diagnosis and management in primary care facilities. It includes simple drug- and dose-specific HTN treatment protocols, measures to ensure availability of essential antihypertensive medications, healthful lifestyle counseling, task-sharing among health care providers, and guidance on health information systems for managing individual patients and tracking primary care facility performance. The HEARTS package has been implemented in primary care facilities across 40 LMICs and enrolled 34 million people in treatment.5 Program evaluations from several countries demonstrated that HEARTS implementation can improve HTN patient retention in care and blood pressure control.6, 7, 8
This study used a previously published CVD simulation model to: 1) translate observed HEARTS program HTN control outcomes in 4 countries (Bangladesh, Ethiopia, Nigeria, and the Philippines) into predicted reductions in CVD morbidity and mortality, assuming national scale-up over 2025-2040; and 2) estimate budget impact associated with this scale-up, as well as the cost-effectiveness and return on investment. It also explored the potential gains in program efficiency from reducing drug prices and sharing tasks more effectively across HTN team members, as has been documented in some countries.
Methods
Our analysis focused on 4 countries selected for this study because they represent: 1) active HEARTS implementation sites where Ministries of Health are currently considering scale-up decisions; 2) regional diversity across Africa and Asia, where the burden of HTN and CVD is high; and 3) countries for which recent good-quality cost and epidemiologic data allow for robust budget impact modeling.
This report uses data on the HTN and cost outcomes of HEARTS package implementation in each country at facilities participating in the program. In each country, the HEARTS package was adapted to suit local health system context and policies,5,9 resulting in somewhat different costs across countries. Each country customized its clinical management protocol for adults with HTN (systolic blood pressure/diastolic blood pressure ≥140/90 mm Hg) based on the WHO-HEARTS technical package. In all 4 countries, treatment was initiated with 5 mg amlodipine. If control was not achieved, a second medicine class was added; if raised blood pressure persisted, drug dosage was intensified or a third class of antihypertensive medicine was added (Supplemental Table 2, Supplemental Figure 1). In HEARTS programs, HTN management services and generic formulations of protocol medications are provided to patients at public sector primary health care facilities. Further details are provided in the Supplemental Material.
Costing approach
Program costs were obtained from program evaluations in Bangladesh,10 Ethiopia,11 Nigeria,7 and the Philippines.12 Costs for human resources (primarily nurses, community health workers, and frontline physicians), first-line antihypertensive medications, and basic diagnostic tests (blood pressure measurement, urine, and blood tests) were extracted from health facility records, surveys, and procurement databases. National wage scales, national drug price registries, and district-level health expenditure reports informed the cost estimates. Costing analysis was conducted in collaboration with local country implementing partners through desk review, key informant interviews, and facility-based data collection. The partners compiled data on training costs, salaries, and supply-chain expenses for antihypertensive medications and other consumables.
Component costs included HTN management team staffing (as part of team-based care), staff time, staff training, medications, and information systems.8 Table 1 summarizes HEARTS package unit costs and computed cost per primary care and HTN-treated patient in the 4 countries. Annual health care workforce wages ranged from $9,520 to $50,000 per primary care doctor and from $7,670 to $28,300 for other professionals (nurses, community health workers, and laboratory technicians). Antihypertensive medicine costs ranged from $0.01 to $0.28 per tablet. Cost data initially collected in local currency units were converted to 2023 International Dollars using the market exchange rate (as of December 30, 2023) and Purchasing Power Parity (PPP) conversion factors for 2023 published by the World Bank.13 For Ethiopia, 2022 PPP values were used due to significant postconflict currency depreciation. This conversion method facilitates meaningful cross-country comparisons; therefore, all the money values are reported in this unit.
Table 1.
HEARTS Program Cost Inputs in 4 Countries (International Dollars, 2023)
| Measure | Bangladesh | Ethiopia | Nigeria | Philippines |
|---|---|---|---|---|
| A. Unit costs | ||||
| Annual wages (including benefits) for health care providers | ||||
| Doctor wage | 48,900 | 9,520 | 33,200 | 50,000 |
| Nurse wage | 25,400 | 5,660 | 27,400 | 28,300 |
| CHW wage | 17,000 | 2,320 | 27,400 | 28,300 |
| Lab technician wage | 20,100 | 7,670 | 27,400 | 28,300 |
| Antihypertensive medicine costs, per tablet | ||||
| ACEI: lisinopril (20 mg) | -- | 0.16 | -- | -- |
| ARB: losartan (50 mg) | 0.28 | -- | 0.21 | 0.09 |
| Calcium-channel blocker: amlodipine (5 mg) | 0.03 | 0.04 | 0.08 | 0.03 |
| Calcium-channel blocker: amlodipine (10 mg) | -- | 0.08 | 0.08 | 0.07 |
| Thiazide diuretic: hydrochlorothiazide (25 mg) | 0.01 | 0.08 | 0.09 | 0.04 |
| B. Computed annual cost per primary care user and per HTN patient | ||||
| Public sector primary care user | 16.00 | 3.00 | 5.99 | 11.00 |
| Hypertensive patient treated | 67.00 | 27.00 | 56.90 | 37.30 |
| Primary care user (reduced cost scenario) | 13.10 | 2.46 | 5.69 | 8.99 |
| Hypertension patient treated (reduced cost scenario) | 58.00 | 23.80 | 52.40 | 32.20 |
Cost data initially collected in local currency units were converted to 2023 International Dollars using the market exchange rate (as of December 30, 2023) and the Purchasing Power Parity (PPP) factors for 2023 published by the World Bank.13 For Ethiopia, costs were converted from local currency to $Int using the 2022 PPP. The more prevalent tablet presentations are outlined. When discrepancies arose between the commonly available dosages and those specified in the protocol, the unit value was adjusted by multiplying it by the corresponding factor. For example, if the data collected pertained to losartan 50 mg tablets but the protocol required 100 mg, the unit value per tablet for the 50 mg dosage was multiplied by 2 to align with the required dosage. Wages are rounded to 3 significant figures to facilitate the numbers' readability. Hydrochlorothiazide cost for Nigeria was retrieved from (O. Erojikwe, Personal communication, 2025).
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker; CHW = community health worker; HTN = hypertension.
Modeling HEARTS HTN control program impact
A Markov cohort simulation model was used to represent the HTN care cascade and estimate potential health gains from improved blood pressure control under assumptions of program effectiveness. This model was published previously and has been described in detail elsewhere.14 Further model details are highlighted in the Supplemental Material. In brief, the model incorporates each country’s demographic structure, current HTN prevalence, awareness, treatment, and control status, health care facility density, and distribution of health care worker human resources. Taking this national population, the model applies event and mortality rate reductions for specific CVD outcomes (ischemic heart disease, hypertensive heart disease, ischemic stroke, and hemorrhagic stroke) from 2020 to 2040. Overall HTN control program effectiveness is expressed as a change in the proportion of patients who are aware, treated, and controlled over time (Supplemental Figure 2). In this study, predicted health benefits in each of the 4 countries depend on changes to the population blood pressure control rate, the final step of the HTN cascade.
National scale translation and evaluation
The national-level scale-up scenario assumed an increase in HTN population treatment coverage by an additional 15 percentage points between 2025 and 2030, relative to the 2024 baseline. Closed-cohort analyses of HEARTS program data were conducted using deidentified individual patient data gathered 2019 to 2024. In Ethiopia, a country with strong administrative data and patient tracking systems, HTN control rates increased as much as 22 percentage points by 24 months after HEARTS implementation. However, to ensure conservative and generalizable projections, we applied a lower-bound estimate observed in a HEARTS patient cohort in Bangladesh (a 15 percentage point increase in HTN control) across all countries in our model. We based the rate of program scale-up on emerging evidence from other HEARTS country programs indicating that up to an additional 3 percent of the population annually could be reached by the HEARTS program if it is expanded rapidly.14 The simulation model translated this real-world robust evidence into estimates of the minimum potential impact of HEARTS scale-up on HTN control.
Table 2 summarizes the 4 countries’ target populations (adults aged ≥20 years), treatment cascades, protocol details, and implementation costs, used for CVD model input parameters. Results from costing studies of initial implementing sites were extrapolated to the national level by assuming that observed improvements in care processes in the HEARTS HTN programs and costs per patient would be generalizable across similar health care facility tiers and regions.
Table 2.
Current and Projected HEARTS Hypertension Program Characteristics in 4 Countries
| Indicator | Unit | Country |
|||
|---|---|---|---|---|---|
| Bangladesh | Ethiopia | Nigeria | Philippines | ||
| A. Baseline population | |||||
| Population 2024 (age 20+) | Persons | 112,000,000 | 60,900,000 | 114,000,000 | 70,900,000 |
| Screened | Persons | 45,800,000 | 27,200,000 | 51,000,000 | 28,800,000 |
| Diagnosed | Persons | 10,200,000 | 3,200,000 | 5,040,000 | 6,630,000 |
| Treated | Persons | 7,660,000 | 2,050,000 | 2,080,000 | 5,420,000 |
| Clinical review beneficiaries | Persons | 56,000,000 | 30,400,000 | 56,000,000 | 35,500,000 |
| B. Hypertension treatment cascade | |||||
| Public sector primary care user | Percent | 50% | 50% | 49% | 50% |
| HTN prevalence 2024 | Percent | 37% | 25% | 31% | 34% |
| Aware 2024 | Percent | 49% | 42% | 29% | 55% |
| Treated 2024 | Percent | 37% | 27% | 12% | 45% |
| Controlled 2024 | Percent | 13% | 9% | 3% | 18% |
| Aware (target 2030) | Percent | 64% | 57% | 44% | 70% |
| Treated (target 2030) | Percent | 52% | 42% | 27% | 60% |
| Controlled (target 2030) | Percent | 28% | 24% | 18% | 33% |
| C. Hypertension patients treated at protocol step | |||||
| Protocol step 1 | Percent | 55% | 55% | 69% | 62% |
| Protocol step 2 | Percent | 42% | 35% | 26% | 34% |
| Protocol step 3-4 | Percent | 3% | 11% | 5% | 4% |
Population estimates come from UNWPP. The proportion of patients in each step of the treatment cascade and protocol step was retrieved from program implementation data. Cost per capita is computed from input unit values and parameters. Numbers are rounded to 3 significant figures to facilitate readability.
UNWPP = United Nations World Population Prospects; other abbreviation as in Table 1.
Return on investment analysis
Costs per disability-adjusted life-year (DALY) averted were calculated using cause-specific disability weights for nonfatal disease conditions from the Global Burden of Disease Study10 and life expectancy data from the United Nations World Population Prospects.11 To contextualize health benefits in economic terms, we valued reduced CVD burden using the value of a statistical life approach.15 Future health outcomes and costs were discounted at 3%, and sensitivity analyses tested variations in this rate.
Assumptions and sensitivity analyses
The analysis assumed observed HEARTS program cascades, effectiveness, and costs will be generalized nationally along with future program scale-up. Costs per public sector primary health care user and hypertensive patient (Table 2) were kept constant over the entire future period and were not adjusted for economies of scale effects or future inflation. As a simplifying assumption, it was assumed patients stayed at the same HTN treatment step (same medication regimen) throughout each calendar year. Incremental cost-effectiveness, budget impact, and return on investment were estimated by comparing the HEARTS scale-up scenario and the status quo or baseline scenario of no HEARTS scale-up.
We also explored potential future economies of scale and gains in program efficiency, based on evidence from some HEARTS countries. Although mechanisms like bulk purchasing and pooled procurement of medicines can reduce medication costs, the estimated savings vary widely, from 15%16 to as much as 98% (or 41-fold).17 To remain conservative, we modeled economies of scale as a 10% reduction in medication prices compared to the standard cost of generic prescribed drugs in the program. Gains in program efficiency were represented as one fewer follow-up visit for patients with controlled HTN via 90-day medication refills, reflecting optimal use of nonphysician health workers, as seen in Nigeria.7 These analyses evaluated the potential impact on the program’s budget of these market and efficiency effects as HEARTS scaled nationally.
Ethics
Ethics approval was not required for the original HEARTS costing studies informing this analysis because the research neither involved human or animal participation nor required consent from human participants. Deidentified HEARTS HTN control program data were provided by country governments under data use agreements with Resolve to Save Lives.
Results
Cost of HEARTS hypertension control
The annual cost of implementing HEARTS per primary care services user in the public sector ranged from Int $3 to 16 across Bangladesh, Ethiopia, Nigeria, and the Philippines (Supplemental Table 1). Figure 1 illustrates the component costs of scaling up the HEARTS program over time. Early in HEARTS implementation (first 1-4 years), health system, human resources, and diagnostic costs would account for 38% of total expenditures. As programs mature, medications become the primary cost, accounting for over 60% of total program spending, reflecting a steady state of long-term HTN management in primary care. The annual cost of HTN treatment ranges from Int$ 27 to 67 per patient due to differences in medicine prices, health care workforce remuneration, and baseline infrastructure costs. Ethiopia, for example, faces lower screening/clinical review unit costs but higher diagnosis costs. Nigeria’s decentralized medication procurement structure leads to higher medication costs. Projected treatment costs per treated patient closely approximate cross-sectional costs estimated directly from the HEARTS costing tool (standardized by 2023 PPP) for facilities in Bangladesh $52,18 Ethiopia $23,19 Nigeria $36,7 and the Philippines $26.12
Figure 1.
HEARTS Hypertension Care Annual Cost by Component Over Time
Cost per primary care user (adult population 20-95+).
National-level HEARTS effectiveness
Under the modeled scenario of increasing treatment coverage by 15 percentage points from each country’s baseline by 2030, standardized CVD prevalence rates would decline over time as more patients achieve blood pressure control (Figure 2). Reductions in mortality rates would be more pronounced because of improved treatment and prevention of acute cardiovascular events. By 2030, this would translate into approximately 2,000 to 5,600 annual lives saved per country, increasing to 5,600 to 13,100 cumulative lives saved by 2040. By 2040, the number of cumulative lives saved would be 120,000 in Bangladesh, 47,000 in Ethiopia, 78,000 in Nigeria, and 82,000 in the Philippines.
Figure 2.
Comparative Effectiveness of Scaling Up HEARTS vs Usual Care
(A) Projected standardized CVD prevalence. (B) Mortality rates. Notes: We used the 2040 UNWPP reference population for age-standardization. Rates are reported per 100,000 population in Dashed lines. CVD = cardiovascular disease; UNWPP = United Nations World Population Prospects.
Budget impact at national scale
Scaling up HEARTS would require a substantial but manageable financial investment in each country. Table 3 presents the cumulative incremental cost for 2025 to 2030 and 2025 to 2040. Total incremental budget impact would vary by country due to population size, baseline coverage, and cost structure. By 2040, the cumulative incremental cost of implementing HEARTS would be $2.9 billion in Bangladesh, $1.7 billion in Nigeria, $0.9 billion in the Philippines, and $0.5 billion in Ethiopia.
Table 3.
Economic Evaluation of Scaling Up HEARTS Hypertension Control Programs in 4 Countries (Total Discounted 2023 $INT)
| Measure | Bangladesh |
Ethiopia |
Nigeria |
Phillippines |
||||
|---|---|---|---|---|---|---|---|---|
| 2030 | 2040 | 2030 | 2040 | 2030 | 2040 | 2030 | 2040 | |
| A. Health outcomes | ||||||||
| Baseline CVD deaths | 2,210,000 | 6,780,000 | 512,000 | 1,630,000 | 1,070,000 | 3,410,000 | 1,430,000 | 4,390,000 |
| Intervention CVD deaths | 2,190,000 | 6,660,000 | 507,000 | 1,580,000 | 1,060,000 | 3,330,000 | 1,420,000 | 4,310,000 |
| Lives saved | 14,500 | 120,000 | 5,020 | 47,200 | 7,230 | 77,500 | 7,830 | 82,000 |
| DALYs averted (discounted) | 128,000 | 960,000 | 43,900 | 365,000 | 56,300 | 506,000 | 78,600 | 668,000 |
| Economic benefits (millions, discounted) | $5,380 | $37,500 | $402 | $3,130 | $1,660 | $14,700 | $4,650 | $40,300 |
| B. Costs | ||||||||
| B1. Base cost scenario | ||||||||
| Baseline total cost (millions) | $4,280 | $10,600 | $494 | $1,330 | $1,840 | $4,930 | $1,850 | $4,640 |
| Intervention total cost (millions) | $5,110 | $13,500 | $627 | $1,840 | $2,250 | $6,640 | $2,110 | $5,570 |
| Incremental total cost (millions) | $826 | $2,940 | $133 | $516 | $409 | $1,720 | $259 | $935 |
| B2. Reduced cost scenario | ||||||||
| Baseline total cost (millions) | $3,440 | $8,520 | $397 | $1,070 | $1,770 | $4,740 | $1,500 | $3,750 |
| Intervention total cost (millions) | $4,170 | $11,100 | $516 | $1,530 | $2,150 | $6,330 | $1,720 | $4,580 |
| Incremental total cost (millions) | $727 | $2,590 | $118 | $459 | $379 | $1,590 | $228 | $823 |
| C. Economic evaluation | ||||||||
| C1. Base cost scenario | ||||||||
| Cost per DALY averted (discounted) | $6,440 | $3,060 | $3,030 | $1,410 | $10,700 | $4,630 | $3,290 | $1,400 |
| Cost per life saved | $64,000 | $32,700 | $29,700 | $14,800 | $63,600 | $30,200 | $37,100 | $15,500 |
| Benefit-cost ratio (discounted) | 6.52 | 12.80 | 3.02 | 6.07 | 4.06 | 8.57 | 18.00 | 43.10 |
| C2. Reduced cost scenario | ||||||||
| Cost per DALY averted (discounted) | $5,670 | $2,690 | $2,700 | $1,260 | $9,860 | $4,250 | $2,890 | $1,230 |
| Cost per life saved | $56,300 | $28,800 | $26,400 | $13,100 | $58,900 | $27,900 | $32,600 | $13,600 |
| Benefit-cost ratio (discounted) | 7.41 | 14.50 | 3.40 | 6.83 | 4.39 | 9.28 | 20.40 | 49.10 |
All monetary values are expressed in millions of 2023 international dollars.
DALYs, economic benefits, and costs are brought to present values in 2025, discounted at a rate of 3%. All values are cumulative over 2025 to the target year, either 2030 or 2040. Numbers are rounded to 3 significant figures to facilitate readability.
CVD = cardiovascular disease; DALYs = disability-adjusted life-years.
Overall HEARTS value for money
By 2040, the mortality and morbidity reductions from scale-up of HEARTS would translate into 365,000 DALYs averted in Ethiopia, 506,000 DALYs averted in Nigeria, 668,000 DALYs averted in the Philippines, and 960,000 DALYs averted in Bangladesh (Table 3). The cost per DALY averted would be below the commonly accepted cost-effectiveness thresholds (ranging 0.5-3 times the country's gross domestic product), and the results are robust to different discount rates (Supplemental Figure 3). The economic benefits of this mortality reduction would vary widely across countries: $37.5 billion gained for the Bangladesh economy, $14.7 billion in Nigeria, $40.3 billion in the Philippines, and $ 3.1 billion in Ethiopia. The Philippines would provide the highest return on investment, with a benefit-cost ratio of 43.1 by 2040, indicating that every dollar spent generates nearly 50 times its value in benefits. Bangladesh, Nigeria, and Ethiopia would also see very favorable benefit-cost ratios, reaching 12.8, 8.6, and 6.1, respectively.
Lowering costs and improving HEARTS program efficiency
Under the alternative lower cost scenario, we assumed that the cost per primary care patient could be reduced by approximately 10 to 15%, with an average cost from $27-$67 to $24-$58 per treated patient, leading to higher net benefits (Supplemental Table 3, Table 3). The incremental cost would decrease by 8% to 12%. Similarly, cost-effectiveness metrics would be improved, with more lives saved per unit of investment. For instance, the cost-effectiveness in Bangladesh would drop from $3,100 per DALY averted under the base scenario to $2,700 under the lowered cost scenario. Similarly, Nigeria and the Philippines could also experience reductions in incremental cost-effectiveness ratios.
Discussion
This analysis leveraged a validated CVD simulation model and observed HEARTS program HTN outcomes and costing data to estimate national-scale impact of improved HTN management in Bangladesh, Ethiopia, Nigeria, and the Philippines. By projecting CVD burden over 2025-2040 and simulating a scenario in which HTN treatment coverage increases by 15 percentage points above baseline by 2030, we provide a forward-looking assessment of the costs and benefits expected with scaling up the HEARTS program nationally in each country (Central Illustration).
Central Illustration.
Budget Impact and Investment Case for HEARTS Hypertension Control Programs in 4 Low- and Middle-Income Countries
All monetary values are expressed in millions of 2023 international dollars. DALYs, economic benefits, and costs are brought to present values in 2025, discounted at a rate of 3%. All values are cumulative over 2025 to the target year 2040. Numbers are rounded to 3 significant figures to facilitate readability. DALYs = disability-adjusted life-years.
Previous analyses of selected HEARTS HTN programs (through October 2022) demonstrated an overall improvement in pooled HTN control rates from 18% to 46%—a 28 percentage-point increase over 4 years.5 However, given the substantial heterogeneity observed across settings, we adopted a conservative estimate of a 15 percentage-point improvement in HTN control for our model. This threshold reflects a realistic lower bound while still capturing meaningful population health benefits from HEARTS scale-up. Our results support that implementing the HEARTS program nationally in Bangladesh, Nigeria, Ethiopia, and the Philippines would yield meaningful gains in health outcomes alongside good overall economic value.
The projected annual cost per HTN patient treated ranged widely, from $27 to $67, reflecting diverse country-specific cost structures and differences in health care system organization. While initial investment costs would be significant, the long-term benefits of lives saved, DALYs averted, and economic returns far outweigh the costs, making a strong case for expanding HTN control programs in these countries. The intervention would be cost-effective, as for every country, by 2040, the incremental cost per DALY averted was well below established willingness-to-pay thresholds (0.5-3 times gross domestic product per capita). These findings align with health economic studies describing and quantifying the value of implementing HEARTS in LMICs3 and broader global assessments of HTN control interventions—such as the 2023 WHO Report on Global Hypertension20—which underscore the value and high-impact potential of scaling evidence-based, primary care–based interventions for noncommunicable disease prevention and control.
Achieving global HTN control is increasingly urgent due to increases in CVD burden because of population growth and aging and increases in some risk factors like obesity and dietary risks.14 This economic-modeling analysis, which was based on real HEARTS program data, provides critical insights to countries to strategically optimize their investments. HEARTS outlines several pathways for system-wide improvement, including streamlining procurement processes to secure affordable, quality-assured antihypertensive medications; integrating HTN management into routine primary care visits; expanding task-sharing by training and licensing nonphysician health workers to manage routine HTN care; and adopting digital tools to improve follow-up and adherence.21 When combined within the HEARTS program, these targeted investments could help public health authorities and budget planners generate considerable gains in cardiovascular health within constrained budgets.22 Moreover, our cost-per-user and cost-per-life-saved estimates offer concrete metrics to support national health authorities and donor priority setting.
Study Limitations
The main strength of this study is that our HEARTS scale-up projections were based on real, observed HEARTS program HTN outcomes and cost data and therefore reflect what is likely to be achieved in the real world if these local programs are further expanded. Nonetheless, several caveats are noteworthy. First, we only estimated the impact of the HEARTS component on HTN control. Although this is the most evidence-driven and most well-implemented element of the package, HEARTS also involves dietary salt reduction, diabetes management, and lipid management. Such other interventions would produce additional health and economic benefits, but their relative cost-effectiveness compared with HTN control is uncertain. Consequently, our figures should be considered conservative, and subsequent studies should quantify the costs and benefits of these additional parts. Second, Ethiopian cost data were affected by currency depreciation and limited local economic data, leading to reliance on default values and assumptions from other countries, reducing precision. Improving local health accounting and updating exchange rates can enhance future analyses of the Ethiopia program. Third, our study focused on the direct programmatic costs of implementing and sustaining the HEARTS HTN control package. We did not explicitly model potential cost savings from avoided CVD events, as standardized data on treatment costs and utilization rates are limited across the study countries. As such, our results should be considered conservative. In reality, reductions in CVD events would likely generate substantial health care cost savings, further lowering the net cost of scale-up and strengthening the investment case for HEARTS. Fourth, differences in implementation timelines and effectiveness parameters required us to make some judgments regarding model inputs and assumptions. Based on previous HEARTS program data, we used a 24-month horizon for Bangladesh and Ethiopia and a 48-month horizon for Nigeria and the Philippines. Longer-term data on real-world effectiveness in the 2 former countries would result in more accurate estimates. Finally, real-world operational issues, such as unbalanced protocol adoption, medicine availability, and long-term funding, are likely to undermine efficacy from modeled levels. However, even under worst-case assumptions, our findings suggest that scaling up HEARTS is highly cost-effective for LMICs.
In conclusion, our economic evaluation found that scaling the HEARTS technical package in 4 diverse LMICs could save hundreds of thousands of lives over the next 2 decades. While the program would require considerable additional resources, it would provide substantial value for money. National HTN programs modeled after HEARTS demonstrate the strategic value of investing in robust, standardized primary care interventions to combat the global burden of CVD.
Funding support and author disclosures
This work was supported by Resolve to Save Lives, which is funded by Bloomberg Philanthropies, the Bill and Melinda Gates Foundation (award OPP1175906), and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgments
The authors thank Deliana Kostova, Jami Husain, and Soumava Basu, from the Division of Global Health Protection, United States Centers for Disease Control, Atlanta, USA, for their assistance with interpreting results HEARTS costing studies for the 4 countries.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For an expanded Methods section as well as supplemental tables and figures, please see the online version of this paper.
Supplemental material
References
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