Ischemic heart disease burden and healthcare system readiness across sub-Saharan Africa

Abstract

Sub-Saharan Africa is experiencing a rapid rise in ischemic heart disease (IHD), creating new challenges for regional health systems. As populations grow and urbanise, lifestyle, metabolic, nutritional, and environmental factors are reshaping the burden of non-communicable diseases. Yet health systems, historically oriented towards communicable diseases and maternal health, show variable capacity to prevent, diagnose, and treat IHD. Despite increasing recognition of IHD, systematic assessments of country-level disease burden and healthcare capacity are limited, leaving gaps for evidence-based policy. Here we address this gap by assessing healthcare system readiness across four domains: health system capacities, primary care, secondary and tertiary care, and health system context. We highlight how limitations in workforce, essential medicines, diagnostics, and policy intersect with upstream drivers such as obesity, hypertension, diabetes, smoking, dietary transitions, urbanisation, and environmental stressors. Meeting these challenges will require coordinated investment, equitable resource allocation, and integrated prevention strategies.

Sub-Saharan Africa (SSA) is undergoing a profound epidemiological transition.¹ Once considered rare, ischemic heart disease (IHD), and atherosclerosis more broadly, is rapidly emerging as a major burden across the region.^2–4 Population ageing and lifestyle changes associated with urbanisation and economic development have driven a sharp rise in the prevalence of cardiovascular disease (CVD) risk factors, including hypertension, diabetes, obesity, and tobacco use.^4,5 Consequently, the burden of IHD in SSA has surged: between 1990 and 2017, the number of IHD-related deaths increased by approximately 74%,² with the region accounting for around 5% of global IHD-related disability-adjusted life years (DALYs),⁶ a measure of overall disease burden that includes years lost due to ill-health, disability, or early death, in 2023. Furthermore, IHD is projected to remain the leading contributor to DALYs in the region through 2050, reflecting a continuing shift from communicable, maternal, neonatal, and nutritional diseases to non-communicable diseases (NCDs).⁷

Despite this rising burden, there is limited systematic assessment of geographic variation in IHD risk, burden, and healthcare capacity across SSA. Most existing studies address broad regional patterns or isolated risk factors, without integrating health-system capacity across primary, secondary, and tertiary care or accounting for key social determinants. The requirements of national healthcare systems for managing IHD differ greatly from those needed for infectious diseases or maternal health, with implications for preventive measures (e.g., treatment of hypertension) and advanced tertiary functions (e.g., coronary artery interventions). Addressing this gap is not only essential for achieving Sustainable Development Goal 3.4,⁸ but is also a central component of the African Union’s Africa Health Strategy 2016–2030⁹ and Agenda 2063¹⁰, both of which explicitly identify NCDs as impediments to the continent’s long-term health and development ambitions.

To address this gap, we analyse publicly available data on IHD burden and healthcare system readiness across SSA. We structure this Perspective around four areas central to IHD, adapted from the Organisation for Economic Co-operation and Development (OECD) Health System Performance Assessment Framework¹¹: (i) health system capacities, encompassing governance, workforce, financing, and guidelines; (ii) primary care; (iii) secondary and tertiary care; and (iv) health system context.

Addressing needs in these key areas is necessary to enable IHD management in these contexts. We contextualise the IHD burden across SSA (Fig. 1a) using the 2023 Global Burden of Disease study⁸ and identify gaps in healthcare system readiness across individual SSA countries in each of the four major areas in the framework. We also emphasise the urgent need for more high-quality data, including imaging-based diagnostics and detailed assessments of regional risk factors, to better understand and target IHD interventions in SSA. Our Perspective highlights the geographic gaps between IHD disease burden and healthcare system readiness, to guide investments and policies toward areas of greatest need.

Fig. 1: Health system capacities and the burden of ischemic heart disease in sub-Saharan Africa.

a, Age-standardized IHD DALYs per 100,000 population in 2023 for each country (points) with 95% confidence intervals (CIs). Countries are denoted by 3-letter ISO codes, and are ordered from lowest (left) to highest (right) burden. Data from the Global Burden of Disease Databank adapted from the 2023 Global Burden of Disease study.⁶ The lower dotted line denotes median value (807.8 per 100k). The comparable estimate from OECD countries is 2,271.7 (95% CI 2,079–2,400) DALYs per 100,000 (upper dotted line). b, National policy and surveillance indicators, comprising the presence of primary NCD and CVD guidelines and evidence of recent (within the past 5 years) national adult risk-factor surveys for hypertension, cholesterol, and tobacco use. Data from WHO Global Health Observatory based on WHO NCD Country Capacity Surveys.⁵⁶ c, Per capita healthcare expenditure (USD) in 2022. Dotted line denotes median value (66.1 USD/capita). The comparable median estimate from OECD countries is 4,057 USD/capita in 2022. Data from WHO Global Health Expenditure Database.⁹⁰

Health system capacities and IHD preparedness

Addressing IHD requires an array of health system capacities, ranging from long-term preventive strategies and surveillance to advanced acute care.¹² Health systems encompass many interdependent capacities, but here we focus on four central areas for IHD preparedness: national cardiovascular guidelines, surveillance capacity, healthcare spending, and the size of the healthcare workforce. National cardiovascular guidelines are a critical starting point, as they provide a framework for consistent, evidence-based practice across diverse contexts.¹³ By shaping prevention programmes, standardising treatment protocols, and accounting for local realities such as medication availability and prevalent risk factors, national guidelines help ensure that patients receive equitable and effective care irrespective of where they enter the health system.^14,15

Despite this, several high IHD burden countries still lack national CVD-specific guidelines, including Mauritania, Gabon and Togo. Overall, approximately 45% of countries in SSA lack such guidance (Fig. 1b). Even where broader NCD strategies exist, the absence of dedicated local CVD guidance leaves clinicians without standardised, evidence-based approaches for prevention, diagnosis, and management. While adoption of international guidelines is useful, adapting them to local contexts is essential to make them relevant to frontline providers, address implementation barriers and enhance local uptake.¹⁶ In this regard, the Pan-African Society of Cardiology (PASCAR) has sought to adapt some international cardiovascular guidance to African contexts. Through a continent-wide hypertension task force, PASCAR developed a 10-point roadmap to achieve 25% control of hypertension in Africa by 2025.¹⁷ The roadmap emphasises simple treatment algorithms, routine risk factor monitoring through the World Health Organization (WHO) STEPwise approach,¹⁸ and reliable access to essential medicines. However, dedicated guidance and task forces for IHD remain limited.

Nevertheless, even well-crafted national CVD guidelines cannot be implemented effectively without reliable data on risk factor patterns. Parallel deficiencies in population-level surveillance further challenge regional responses. While several countries have implemented national CVD guidelines, many lack regular surveys of key atherosclerotic risk factors such as tobacco use, hypertension prevalence, and lipid/cholesterol levels (Fig. 1b). Regular risk factor surveys are essential to track disease determinants, design targeted policies, and evaluate programme effectiveness. Although the WHO STEPS survey framework measures several major risk factors,¹⁸ its use has been inconsistent across the region due to insufficient resource allocation, and in many countries with high IHD burdens, such surveys remain sporadic or absent. This limits the capacity of governments to monitor trends or assess the reach of interventions.

To address this, PASCAR and the World Heart Federation have developed national scorecards to map country-level capacity for cardiovascular care and identify gaps in surveillance, guidelines, and medicine availability.¹⁹ Prevalence and management surveys of hypertension and high cholesterol levels are particularly critical, given the high rates of undiagnosed and uncontrolled hypertension in the region and the well-established role of dyslipidaemia in CVD. Additionally, effective medicines for these conditions are often more affordable than many other essential cardiovascular therapies,^1,20,21meaning they represent highly modifiable risk factors with substantial primary and secondary prophylactic potential. Stronger surveillance of dietary risk factors, obesity, and diabetes would provide a more comprehensive picture of cardiometabolic health in SAA. Without such information, policymakers may be constrained to reactive strategies, widening the gap between the global evidence base of known risk factors and the data needed to initiate interventions effectively at the national level across SSA.²²

National guidelines alone are insufficient without the resources and workforce to implement them. A well-trained and equitably distributed health workforce is essential for primary, secondary, and tertiary service delivery; however, many countries continue to face persistent shortages, uneven distribution, and workforce migration that weaken preparedness for IHD.^23,24 For instance, there are approximately 0.2 cardiologists per 100,000 population in SSA, compared to a 35-fold higher level in the United States, with over 7 per 100,000, highlighting stark disparities in specialist availability.²⁵ Paradoxically, several countries in SSA are also experiencing a surplus of trained health professionals who remain unemployed.²⁶ The solution to the needs-based shortage is therefore not simply to expand education and training, but also to ensure equitable distribution, retention, and meaningful employment of health workers across levels of the health system.^27,28 Current healthcare expenditure is also highly variable across SSA and far below the OECD average (Fig. 1c). Several countries, including South Africa, Seychelles and Namibia, have healthcare expenditures several times higher than countries such as Niger, Ethiopia and Somalia, driving geographic inequities in healthcare capacity across the region. Coordinated national planning is therefore necessary to align resources with the burden of disease, reduce geographic inequities, and build resilience across all levels of care.²⁹

Primary care management of IHD

Primary care plays a critical role in the primary and secondary prevention of coronary events such as myocardial infarction and its many complications, including heart failure, arrhythmia, and sudden cardiac death. Early screening for cardiovascular risk factors is a cornerstone of IHD prevention and requires reliable diagnostic capacity within the primary care sector to identify individuals at risk. Validated atherosclerosis risk prediction tools, such as PREVENT,³⁰ Framingham Risk Score, and ASCVD,³¹ are widely used internationally; the latter accounts for race, reflecting dyslipidemia differences (e.g., in lipoprotein(a))³² and underscoring the need for regionally adapted models like the WHO CVD risk charts.³³ While blood pressure measurement is generally accessible in the public sector (defined as >50% availability at public healthcare facilities - a relatively low threshold), several countries in SSA lack capacity for cholesterol measurement (Fig. 2c), despite the existence of innovative point-of-care techniques.³⁴ Notably, this gap in risk factor surveillance includes countries with high IHD burdens, such as Gabon, The Gambia, and Guinea-Bissau.

Fig. 2: Primary care capacity, cardiovascular workforce, and essential medication availability across sub-Saharan Africa.

a, Density of general medical practitioners per 10,000 population in 2023; countries ordered from lowest to highest IHD DALYs. Dotted line denotes median (1.35 GPs per 10,000). Data from the WHO National Health Workforce Accounts Data Portal.⁴⁶ Seychelles not visualized as an outlier (65.96 per 10,000). b, Availability of essential cardiovascular medications in the public sector in 2023. General availability is defined as medications being found in 50% or more pharmacies. Data from the WHO Global Health Observatory.⁵⁶ c, Availability of primary care diagnostic tests (blood pressure and total cholesterol measurements) in 2023. General availability is defined as tests being found in 50% or more healthcare facilities. Data from the WHO Global Health Observatory.⁵⁶

Access to medications

The WHO’s HEARTS technical package³⁵ highlights that improving access to basic diagnostics and medicines is fundamental to scaling up CVD prevention and management in low and lower-middle income countries (LLMICs), including those in SSA. The availability of evidence-based medications, such as angiotensin-converting enzyme (ACE)-inhibitors, beta-blockers, calcium channel blockers, and statins, is essential for both primary and secondary prevention of IHD.³⁶ While these drug classes are included on the WHO Model List of Essential Medicines, their translation into national essential medicines lists (NEMLs) across SSA has been inconsistent.³⁷ Consequently, these drugs remain inconsistently available,^38,39 with only 18 out of 47 (38%) countries in the region reporting general availability of statins in the public sector (Fig. 2b). Reasons for this include weak procurement systems, a lack of local production, and outdated NEMLs that constrain access to essential medications, creating major barriers to consistent care for patients at high cardiovascular risk.^40–42

These systemic challenges are underscored by the fact that several high IHD-burden countries, including Gabon, the Republic of the Congo, and Côte d’Ivoire, lack reliable access to cornerstone therapies such as ACE-inhibitors, beta-blockers, calcium channel blockers, and statins. As a result, many individuals with established CVD do not receive the full range of recommended secondary prevention medications, despite strong evidence that these therapies significantly reduce recurrent events and premature mortality.^36,43 Even when medicines are available, affordability remains a barrier. A month of generic hyperlipidemia treatment in private pharmacies can cost the equivalent of nearly five days’ wages for the lowest-paid worker, with originator brands costing substantially more.⁴⁴ Fixed-dose combinations (FDCs), also known as polypills, have also been proposed as a strategy to reduce barriers to consistent therapy.⁴⁵ However, the effectiveness of this approach in SSA will depend on building strong procurement and supply systems to ensure that these combination medications can be reliably accessed and distributed.

Healthcare workforce

Ensuring sufficient healthcare workforce capacity is equally critical to the successful implementation of these initiatives. There are stark variations in the density of general practitioners (GPs) across SSA (Fig. 2a), with countries such as Eswatini (5.05 GPs per 10,000), South Africa (5.00), and Namibia (5.18) having more than 10 times the density of GPs compared with countries such as Niger (0.35), Togo (0.36), and Senegal (0.37).⁴⁶ Nevertheless, even in comparatively better-staffed countries, the density of GPs per 10,000 population remains substantially lower than that observed in high-income settings such as the United Kingdom (7.86) and South Korea (7.03).⁴⁶ Although medical education capacity in SSA has expanded in recent years,⁴⁷ persistent challenges, including workforce migration and ”brain drain”, uneven distribution of clinicians, and limited public-sector hiring,⁴⁸ continue to limit the ability of primary care systems to address the growing burden of IHD. Task-shifting in primary care to other health care workers, such as nurses, could represent a viable approach in countries facing this challenge.⁴⁹

Capacity in secondary and tertiary settings

Secondary and tertiary care services are central to managing IHD, particularly in acute presentations where timely interventions can substantially reduce morbidity and mortality.⁵⁰ Long-term management through secondary prevention is equally critical. These efforts rely on consistent availability of proven pharmacologic therapies, including anti-platelets, statins, ACE-inhibitors, beta-blockers, calcium channel blockers, and anticoagulants, which are often underutilised due to systemic constraints.⁵¹ To reduce the disproportionate IHD mortality seen among populations of lower socioeconomic status in LLMICs,⁵² strengthening acute coronary care and improving secondary prevention are imperative.⁵³

Capacity for acute care

Capacity within secondary and tertiary systems varies widely across SSA,⁵⁴ with profound implications for the management of acute ischemic events. The availability of advanced cardiac interventions is highly uneven. Only a small fraction of countries report capacity for coronary artery procedures such as bypass surgery and percutaneous coronary artery interventions (PCI; stenting) (Fig. 3a),⁵⁵ leaving much of the region dependent on medical therapy alone. For example, several high-burden countries, including Togo, Eswatini, and Republic of the Congo, report no general public availability of coronary artery procedures despite a substantial IHD burden (Fig. 3a). Similarly, while availability of thrombolysis is reported in some public health systems in SSA, coverage is incomplete, and availability of thrombolytic agents such as alteplase for myocardial infarctions and ischemic strokes is even more restricted (Fig. 3a). In Ghana, Liberia, and Guinea-Bissau, where the IHD burdens are among the highest in SSA, thrombolysis is not consistently available. This scarcity is particularly consequential in acute myocardial infarction, where delays or lack of access to reperfusion therapies substantially increase mortality.⁵⁰

Fig. 3: Secondary and tertiary care functions across sub-Saharan Africa.

a, Availability of selected hospital-based procedures for cardiovascular care in the public sector in 2023, with countries ordered from lowest to highest burden of IHD DALYs in 2023. Procedures shown are intravenous alteplase for stroke management, thrombolytic therapy in the public health system, and coronary procedures such as coronary bypass or stenting in the public sector. b, Density of diagnostic imaging scanners (MRI and CT) per million population in the latest available year (2013 or 2021). All data from the WHO Global Health Observatory.⁵⁶ c, Density of hospital beds per 10,000 population in the latest available year (2004 to 2021)⁵⁶ Dotted line denotes median value (8.99 per 10k). Missing bars denote missing data for SOM, SSD and DJI.

Diagnostic imaging

Diagnostic imaging capacity also shows equally stark disparities. Computed tomography (CT) and echocardiography are critical not only for CVD diagnostics, but also for ruling out competing diagnoses in acute presentations. While cardiac magnetic resonance imaging (MRI) is not a first-line modality for ischemic heart disease diagnosis, it contributes to its workup. Yet many countries report limited or absent access in the public sector, with most imaging capacity densities in SSA measured in low single digits per million population (Fig. 3b), as compared to countries such as Türkiye, Canada and Spain, where the number of MRI units alone exceeds 10 per million.⁵⁶ This shortage reinforces the reliance on clinical bedside diagnosis alone, which increases uncertainty and delays definitive management.⁵⁷ Compounding this issue is the shortage of trained imaging specialists; however, emerging artificial intelligence tools for automated image interpretation offer a promising means to partially bridge this gap in resource-limited settings⁵⁸. Similarly, basic infrastructure like hospital beds remains limited in several countries (Fig. 3c); this affects not only routine inpatient care but also the ability to manage acute cardiac emergencies that require immediate hospitalisation.

These country-level differences illustrate a geographic mismatch between IHD burden and healthcare capacity at advanced levels of care. Countries with high IHD DALY rates often lack the secondary and tertiary infrastructure necessary to provide timely and effective treatment. Addressing these disparities requires investment in physical resources and the development of a specialised workforce to operate advanced technologies and deliver complex interventions. Several African initiatives have strengthened primary care to improve detection and management of cardiovascular risk, including the Hypertension Treatment in Nigeria (HTN) program,⁵⁹ which explicitly adapts the WHO HEARTS package, as well as Healthy Heart Africa⁶⁰, Ghana Heart Initiative⁶¹ and the Malawi NCD Brite Consortium⁶². Without such initiatives being applied to secondary prevention and care, the burden of preventable morbidity and mortality from atherosclerotic events will likely continue to rise across the region.³

Health system context

Assessing healthcare system readiness for IHD requires accounting for the conditions under which the systems must operate. In SSA, environmental exposures, metabolic risk factors, and social determinants shape both the volume and complexity of IHD presentations that health systems must be equipped to manage. Among these, environmental exposures have recently gained increasing recognition for their effects on cardiovascular disease as summarized in a recent systematic review.⁶³ These exposures are diverse; they include high temperatures, ambient air pollution, noise, chemical pollutants such as metals (e.g., lead, cadmium, arsenic), and extreme events such as flooding and wildfires, with heat and air pollution representing particularly important exposures in SSA.^64,65

SSA is particularly susceptible to extreme heat, with considerable geospatial variation across the region (Fig. 4a). The frequency of heat extremes is projected to rise in coming decades, particularly in countries lying along the equator.⁶⁶ Observational studies have highlighted the cardiovascular consequences of temperature, showing that even modest increases in ambient temperature can elevate both morbidity and mortality,⁶⁷ with each one degree Celsius rise in temperature associated with a two percent increase in CVD-related mortality.⁶⁸ High temperatures influence cardiovascular function through mechanisms including dehydration and activation of both endothelial cells and leukocytes.^64,67

Fig. 4: Health system context across sub-Saharan Africa, including environmental exposures, cardiometabolic risk factors, and treatment coverage, shown as standardized z-scores (colour scale) and absolute values (numbers).

a, Environmental variables for each country, including average temperature (°C), heat index days with heat >35 °C (apparent temperature taking account of humidity), annual mean PM_2.5 air pollution (μg/m³; fine particulate matter <2.5 μm in diameter), and number of days with precipitation >50 mm (extreme rainfall events), in 2024. Countries are ordered by IHD DALYs in 2023. Data from the World Bank Climate Change Knowledge Portal.^91,92 b, Key cardiometabolic and communicable disease risk factors in 2022, including age-standardized adult obesity, diabetes, hypertension, mean non-HDL cholesterol, alcohol consumption per capita, and HIV prevalence (ages 15–49). Estimated age-standardized tobacco use prevalence (ages 15+) for 2025, extrapolated from previous survey data using the methodology by Bilano et al.,⁹³ is also shown. Missing values indicated in grey. Data from the WHO Global Health Observatory.⁵⁶ c, Treatment coverage indicators, including diabetes treatment coverage, hypertension diagnosis coverage, and hypertension treatment coverage in 2022. Data from the WHO Global Health Observatory.⁵⁶

Acute heatwaves can also precipitate sudden cardiovascular stress, triggering events such as myocardial infarction and stroke.⁶⁷ Countries such as Djibouti, Senegal, and The Gambia experience particularly high heat exposure, with numerous days each year exceeding a heat index of 35 degrees Celsius (Fig. 4a). Many of these countries also carry a substantial IHD burden (Fig. 1a), amplifying the public health impact of heat exposure. Furthermore, common medications used to manage IHD, such as beta-blockers, can impair thermoregulation, increasing susceptibility to heat-related cardiovascular complications.⁶⁹ Together, these environmental pressures represent an emerging driver of cardiovascular risk in the region.

Air pollution has also emerged as a major cardiovascular risk factor, with exposure to fine particulate matter (PM_2.5) promoting atherosclerosis and destabilising existing plaques, thereby increasing the risk of acute ischemic events.⁷⁰ Consequently, the wide variation in air pollution across SSA (Fig. 4a) likely contributes to regional differences in IHD incidence and outcomes. Household air pollution from the use of solid fuels for cooking has also been linked to coronary heart disease.⁷¹ Similarly, extreme weather events can increase IHD risk, with air pollution’s cardiovascular effects amplified in severely drought-affected regions.⁷² These environmental exposures also intersect with social determinants of health, including poverty, low education, and limited access to healthcare, which amplify vulnerability and contribute to geographic disparities in IHD burden.⁷³

Metabolic, lifestyle, and infectious factors further influence IHD risk, often in interaction with environmental and social determinants. There are stark differences in obesity rates and diabetes prevalence, both of which contribute to the growing burden of IHD. The highest age-standardised rates of obesity among adults are in South Africa (30.8%), Eswatini (30.1%) and Seychelles (29.4%), with large relative differences compared to the lowest rates of obesity in Ethiopia (2.8%), Madagascar (4.3%) and Eritrea (4.8%).⁵⁶ Conversely, malnutrition has also been associated with coronary calcification,⁷⁴ highlighting a potential double burden of disease. Tobacco use also remains an important modifiable contributor to IHD risk, with substantial regional variation across SSA (Fig. 4b); in countries such as Madagascar, Seychelles, and Lesotho, more than one in five adults use tobacco, whereas prevalence is below one in twenty in Nigeria and Ghana.

Hypertension and diabetes prevalence are geographically highly variable (Fig. 4b). The highest age-adjusted hypertension rates (systolic ≥140 mmHg, diastolic ≥90 mmHg, or on medication) are observed in Sao Tome and Principe (45.1%), Seychelles (44.3%) and Botswana (44.1%) (Fig. 4b), while the lowest rates are in Eritrea (23.7%), Ethiopia (27.4%), and Malawi (29.5%) (Fig. 4b).⁵⁶ Treatment coverage also varies sharply: Seychelles (55.2%), South Africa (46.5%), and Namibia (44.0%) have the highest coverage, compared with Rwanda (10.6%), Niger (13.4%), and Tanzania (15.2%) (Fig. 4c).⁵⁶ Similar disparities exist for diabetes management (Fig. 4c).

HIV is an important infectious contributor, with HIV-positive individuals facing higher rates of cardiovascular disease.⁷⁵ Chronic systemic inflammation, which persists even with effective antiretroviral therapy, accelerates atherosclerosis by promoting endothelial dysfunction, immune cell infiltration, and plaque formation.^75,76 Given the considerable variation in HIV prevalence across SSA (Figure 4b), these patterns are likely to contribute to regional disparities in IHD incidence and outcomes. Integration of IHD screening into existing HIV and tuberculosis care programmes represents a promising strategy, leveraging established infrastructure to reach high-risk populations.⁷⁷ One recent trial conducted in Uganda and Tanzania demonstrated that chronic care services for diabetes and hypertension can be successfully integrated into existing care without compromising outcomes for people with HIV.⁷⁸

Together, these factors define the risk landscape that health systems in SSA must be prepared to address; their geographic variation means that capacity gaps identified in preceding sections are likely to be most consequential in settings where these upstream pressures are greatest.

Future policy outlooks

Policy responses to IHD in SSA must balance immediate gaps in service delivery with long-term structural reforms. At the clinical level, strengthening primary care as the entry point for cardiovascular prevention is crucial. Ensuring public sector access to diagnostic tests such as lipid/cholesterol measurements, as well as increasing the general availability of medications such as antihypertensives and statins, is also imperative for prophylactic management. Despite their inclusion on the WHO Model List of Essential Medicines more than a decade ago, statins remain absent from NEMLs in many SSA LLMICs.³⁹ Where public sector coverage is incomplete, the costs of care fall disproportionately on individuals through out-of-pocket expenditure, potentially driving further socioeconomic inequities in IHD outcomes and pushing vulnerable individuals into financial hardship.²²

National CVD guidelines adapted to local contexts will remain an essential foundation, but will only translate into impact if paired with sustainable financing, strong procurement systems, and strategies to train, retain and distribute the health workforce more evenly. For example, the Nigeria Hypertension Control Initiative implemented a drug revolving fund (a self-sustaining system where medication sales are used to replenish stock), which substantially reduced medication costs and improved access to essential antihypertensives.⁷⁹ Likewise, investing in surveillance systems and reviving previously successful prevalence surveys are equally important, with consistent data on risk factor prevalence and treatment coverage crucial for shaping future iterations of guidelines and policy. Here, consistent funding for the WHO STEPS survey¹⁸ and its subsequent implementation would be a welcome development to increasing consistent data collection on NCD-relevant risk factors.

At the same time, tackling CVD cannot be done through the health sector alone. Rising rates of obesity,⁸⁰ dietary health transitions,⁸¹ urbanisation, and environmental stressors such as extreme heat⁸² will shape the trajectory of IHD across the region. Policy approaches that integrate cardiovascular prevention into wider agendas, including urban planning to cool populated areas,⁸³ removing subsidies to harmful products,⁸⁴ increasing sustainable availability of healthy foods,⁸⁵ poverty interventions,⁸⁶ improved access to health insurance and introducing public health policy measures to curb tobacco and alcohol use⁸⁷, including taxes and higher prices (Fig 4d), can deliver population-level impact.

Novel awareness strategies in schools, communities and through digital platforms, building on previous similar initiatives in SSA, will be important to increase recognition of cardiometabolic risk factors and treatment options.⁸⁸ Community-based and home-based models of hypertension management, such as those recently tested in rural South Africa, also offer promising strategies to extend care beyond clinic settings and improve blood pressure control.⁸⁹ These measures must be designed to reduce socioeconomic and geographic inequities, ensuring that lower-income groups benefit alongside more affluent populations. The future of IHD in SSA will therefore depend on how well health system reforms are connected to broader social and environmental policies.

Conclusion

Managing and treating IHD requires a coordinated approach that integrates initiatives across primary, secondary, and tertiary care, alongside system-level strategies to mitigate risk factors, reduce IHD burden, and shape policies addressing key aspects of prevention and treatment. Amidst a profound epidemiological transition, the expected increases in IHD burden in SSA require expanding the healthcare workforce capacity, improving diagnostic services, and increasing access to essential medicines. In parallel, there is an urgent need for more comprehensive data, including imaging-based diagnostics and a detailed understanding of regional risk factors, to accurately measure disease burden and guide targeted interventions. Given that the true burden of IHD remains uncertain owing to limited surveillance and scarce diagnostic data, addressing these deficiencies can help ensure equitable care and meaningful progress in cardiovascular health across the region.

Code availability

Code for figures can be found at: https://github.com/MLGlobalHealth/IHD_SSA