Systematic review of cardiovascular care delivery across health systems in the Asia–Pacific: a regional roadmap for strengthening cardiovascular care

Summary

Background

Achieving universal health coverage in the Asia–Pacific requires stronger, more equitable access to high-quality cardiovascular disease (CVD) services. Yet, despite the region's vast diversity in health systems and resources, there is limited consolidated evidence describing how CVD care is organised, financed, and delivered across Asia–Pacific.

Methods

This document synthesises evidence from a systematic review and Global Burden of Disease data, structured using Donabedian's framework. It provides: (1) an overview of health system structures for CVD care across the Asia–Pacific; (2) case studies illustrating how system processes influence CVD prevention and treatment; and (3) country-level assessments of health system performance, spending efficiency, and associated cardiovascular outcomes, alongside forecasts of health expenditure and CVD burden from 2022 to 2050.

Findings

Many low-to-middle income countries (LMICs) in the Asia–Pacific face challenges in ensuring accessible, high-quality CVD services without substantial policy action and investment. Fragmented primary and secondary care systems, uneven financing models, and limited quality infrastructure have contributed to stalled improvements in cardiovascular health. In contrast, high-income countries must address rising cardiometabolic multimorbidity in ageing populations, requiring transitions from acute inpatient care to integrated, multidisciplinary community-based models that improve quality while managing costs.

Interpretation

These findings underscore the need for tailored, equity-focused strategies that enhance access, quality, and efficiency of CVD care across diverse health system contexts, accelerating progress in a populous yet resource-constrained region.

Funding

This Commission is partly supported by funding from SingHealth Duke-National University of Singapore Cardiovascular Sciences Academic Clinical Programme, the National Medical Research Council of Singapore, and the Stafford Fox Foundation.

Research in context.

Evidence before this study

We searched PubMed on 7 September 2025, using keywords related to “healthcare access”, “healthcare quality”, and “healthcare process”. 61 studies (50 reviews and 11 guidelines) were included, with six additional articles identified through hand-searching. The study uses Donabedian's approach as the framework for evaluating systems of care in the Asia–Pacific, structured around the triad of structure, process, and outcome. In addition, we studied the current and forecasted health expenditure and CVD burden. This was retrieved from the Institute for Health Metrics and Evaluation Global Health Data Exchange, specifically from the Financing Global Health database. For CVD burden, data on mortality and disability-adjusted life years were obtained from the Global Burden of Disease (GBD) 2021 study. We included countries and territories across the Asia–Pacific region for the period from 1995 to 2050.

Added value of this study

This study provides the first integrated assessment of cardiovascular care systems in the Asia–Pacific by combining systematic review findings with CVD burden estimates and health financing data. We also included regional forecasts of health expenditure and CVD burden to 2050. Using Donabedian's framework, it links system structures and processes to CVD outcomes, incorporates analyses of healthcare access and quality, examines expenditure patterns by financing source, and evaluates system efficiency.

Implications of all the available evidence

This study highlights the critical and diverging needs across the region, including substantial structural and financing reforms in low-to-middle-income countries to expand access and quality, and system redesign in high-income settings to address ageing-related multimorbidity and shift care towards integrated community-based models. These findings support region-specific, equity-focused strategies to strengthen CVD prevention, treatment, and health system performance across the Asia–Pacific.

Introduction

Despite the accelerated pace of progress in cardiovascular disease (CVD) prevention and treatment advancements within the Asia–Pacific,¹ the inequalities in health systems, as well as personal accessibility and quality of healthcare, have led to significantly slower gains in CVD care, particularly in low-to middle-income countries (LMICs) within the region.² On the other hand, the care delivery value chain priorities differ in high-income Asia–Pacific countries, given the enlarging cardiometabolic multimorbidity burden in the ageing population, resulting in increasing healthcare costs and the shifting patterns towards community-based care.³ As one of the world's fastest-growing economies, the regional health community must remain cognisant of the economic influence on the transitions in cardiovascular health financing in the Asia–Pacific. Regional patterns have revealed that low-income Asia–Pacific countries are most reliant on development assistance for health (DAH), while middle-income Asia–Pacific countries with stronger domestic health spending systems are shifting away from DAH towards out-of-pocket and government health spending.⁴ Tracking these patterns of health spending and associated CVD outcomes across the socioeconomic spectrum will be critical in ensuring LMICs in the Asia–Pacific are transitioning towards self-sufficient health systems funding.⁴ Asia–Pacific is home to more than two-thirds of the world's population, and bears the largest share of the global CVD burden.⁵ Coupled with stagnated development assistance and political uncertainties, there is a heightened emphasis on universal health coverage in the Asia–Pacific.²

Measuring and subsequently improving the access and quality of health systems has emerged as a key tenet of global health policy to attain universal health coverage. Especially in the Asia–Pacific, with its vast heterogeneity in health systems and financial capabilities, there is an urgent need to enhance access to quality healthcare across CVD service areas for all populations, best achieved through cardiovascular services coordinated across the continuum of care throughout an individual's life course. Immediate policy attention towards the significant geographical inequalities is needed to bridge the widening gap in systems of care and the growing CVD burden experienced by local communities.² However, there remains a paucity of literature on the systems of care and health system performance across the socioeconomic spectrum within the Asia–Pacific. The objectives of this report are to provide an overview of 1) health system structures in CVD care delivery across the Asia–Pacific; 2) the current status and influence of case studies on health system-related processes in CVD care; and 3) country-level evaluations of health system performances, health spending efficiencies, and their associated cardiovascular outcomes, alongside forecasted health expenditure and CVD burden from 2025 to 2050 (Central Illustration). By utilising the consolidated evidence, the dual aim of this consensus document is to generate a preliminary set of potential solutions and future directions for improving health system structure, processes and outcomes in cardiovascular care delivery within the region. The Lancet Commission aims to present a snapshot of Asia–Pacific's development in CVD systems of care, identify areas where progress must be accelerated, inform the effective allocation of resources, and improve the efficiency of health spending to meet regional cardiovascular health goals and improve quality of care (Box 1). For funders and policymakers, these estimates are critical for identifying funding gaps, prioritising scarce resources, and investing to improve the access and quality of healthcare and meet the ever-changing cardiovascular health needs in the Asia–Pacific.⁶

Central Illustration.

Quality indicators for health systems and cardiovascular care in the Asia–Pacific: opportunities and the road ahead. APAC, Asia–Pacific; CVD, cardiovascular disease; CV, cardiovascular; LMICs, low-to-middle income countries; HICs, high-income countries; HAQI, Healthcare Access and Quality Index; EMS, emergency medical services; CR, cardiac rehabilitation; EHR, electronic health record; EDSS, electronic decision support system.

Methods

Overview and definitions

This study combines expert consensus development on the systems of care in the Asia–Pacific, with a comprehensive analysis of health expenditure and CVD burden across the Asia–Pacific region. Without an officially established delineation of its boundaries, the constituent countries of the Asia–Pacific region differ depending on the classification or institutional framework applied. In the context of this analysis, Asia–Pacific includes countries categorised by the World Health Organisation into the South-East Asia Region and the Western Pacific Region. The complete list of countries included in this study is provided in the Supplementary Table S1. This study adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) statement.⁷

Systematic review

A systematic review was conducted to evaluate healthcare access, quality, and cardiovascular outcomes across the Asia–Pacific region. A PubMed search was conducted on September 7, 2025, using keywords synonymous with “healthcare access”, “healthcare quality”, and “healthcare process”. The review was not registered prior. The full search strategy used in PubMed is described in Supplementary Table S2. A total of 844 relevant articles were identified of which 44 were clinical practice guidelines. The review incorporated articles on cardiovascular healthcare access and quality in Asia–Pacific countries, as well as on the associations between health system performance and CVD outcomes.

Three blinded authors (RG, BC, YC) screened through the full text of the articles. Discrepancies were resolved by consensus with a senior author (NC). After exclusion of 783 articles, a total of 61 articles, including 50 reviews and 11 clinical guidelines, were included in this study. An additional six articles were added using a hand sieve (Supplementary Figure S1).

Expert consensus methodology

The study uses Donabedian's approach8, 9, 10 as the framework for evaluating systems of care in the Asia–Pacific, structured around the triad of structure, process, and outcome. In brief, “structure” denotes the setting in which care occurs (e.g. human, medical, intellectual resources for the provision of healthcare), “process” refers to the components of care delivered (e.g. patient-related processes such as referral and intervention rates, and organisational processes such as pharmacotherapy supply), and “outcome” describes the effects of healthcare on the CVD status of the population (e.g. mortality, morbidity, quality of life).8, 9, 10

While the Donabedian framework is a widely used model for evaluating healthcare quality, it has its inherent limitations. A primary challenge lies in the practical application of its domains, as the distinctions between ‘structure,’ ‘process,’ and ‘outcome’ can be ambiguous and may overlap, particularly within the complex, multi-faceted health systems found across the Asia–Pacific.¹¹ Furthermore, the framework may not adequately capture less tangible, yet critical, aspects of care, such as psychosocial factors and the quality of the patient-physician relationship.¹² Despite these constraints, the Donabedian framework was selected for its established utility in providing a clear and systematic structure to assess healthcare systems, providing a robust roadmap of the key components of cardiovascular care delivery in the region.

To provide a cohesive overview of healthcare system processes in the Asia–Pacific, representative case studies were selected to illustrate how components of cardiovascular care delivery influence regional CVD prevention and treatment. This selection prioritises a systemic, comprehensive approach to understanding regional healthcare processes over fragmented descriptions of localised delivery. While acknowledging that case studies have inherent limitations, they offer critical insights into the complexities of dynamic regional CVD health system processes.

Data sources

Health expenditure and CVD burden data were derived from the Institute for Health Metrics and Evaluation Global Health Data Exchange, specifically from the Financing Global Health database.¹³ We included countries and territories across the Asia–Pacific region for the period from 1995 to 2050. We obtained comprehensive health expenditure estimates broken down by financing source, age, sex, and country from various data sources, including government health accounts, household expenditure surveys, national health accounts, and international financial tracking systems. All estimates were downloaded from the Global Health Data Exchange website.¹³ For CVD burden, data on mortality and disability-adjusted life years were obtained from the Global Burden of Disease (GBD) 2021 study.¹⁴

Healthcare access, quality and expenditure measurement

The GBD study has developed the Healthcare Access and Quality (HAQ) Index, which enables global comparisons of healthcare access and quality estimates across countries.^2,15 In the GBD 2021 study, the HAQ Index represented a range of healthcare services addressing several causes of disease considered amenable to healthcare, including noncommunicable diseases such as CVD and diabetes.² The HAQ Index was derived from principal component analysis, yielding an overall score for personal healthcare access and quality for each country on a scale of 0–100.² Using the GBD dataset, the present study examined national HAQ Index scores in relation to other correlates of health system performance and CVD-specific morbidity and mortality estimates. The distribution of the HAQ Index was also examined across levels of socioeconomic development using the Sociodemographic Index (SDI). The SDI is a summary correlate of overall development, based on mean income per capita, educational attainment, and total fertility rates.¹⁶ However, because the HAQ Index captures several factors that influence service access and quality across the continuum of CVD care, it is challenging to differentiate the extent to which access contributes to quality from other potential drivers.¹⁷ As such, other correlates of location-specific financial measures, such as total health expenditure per capita, were examined. The full methodology has been described previously.^2,6

We analysed total health expenditure disaggregated by financing source: government health expenditure (public sector spending through ministries of health and other government entities), prepaid private expenditure (private insurance and prepaid health plans), out-of-pocket expenditure (direct household payments), and development assistance for health (international aid for health purposes). All expenditures were measured in both nominal and purchasing power parity (PPP)- adjusted US dollars (USD). We calculated per capita spending, expenditure as a percentage of gross domestic product, and rate of total health expenditure by source to enable cross-country comparisons.

Cardiovascular disease burden assessment

CVD burden was quantified with age-standardised disability-adjusted life years (DALYs) and mortality rates per 100,000 population, derived from GBD estimates. Estimates of DALYs were calculated by accounting for both fatal and non-fatal health outcomes. Premature mortality was captured through years of life lost, which was estimated by multiplying the number of deaths at each age by the standard life expectancy remaining at that age. Non-fatal outcomes were represented by years lived with disability, quantifying the extent of health loss due to living with disease. The overall disease burden, expressed as DALYs, was derived by summing years of life lost and years lived with disability, disaggregated by age, sex, location, year, and cause.¹⁸

Statistical analysis

This study presents both crude estimates, reflecting the direct burden on health systems, and age-standardised rates, which adjust for differences in population age structures. Subgroup analysis was performed using the SDI,¹⁹ a composite measure that incorporates per capita income, educational attainment, and total fertility rate to generate a summary score representing the underlying socioeconomic development conditions that influence health outcomes within each country.¹⁸ We classified countries into five SDI groups: low, low-middle, middle, middle–high, and high. Additional stratification was conducted using HAQ Index deciles, which provide a standardised measure of health system performance based on risk-standardised death rates from causes amenable to healthcare.⁶ We analysed trends from 1995 to 2021 and examined projections from 2022 to 2050. Our analysis examined temporal patterns in health expenditure by source and country, trajectories of CVD burden across socioeconomic categories, and relationships between spending patterns and health outcomes. We assessed the efficiency of health systems by examining the relationship between expenditure inputs and cardiovascular health outcomes.

Projected estimates

Projected estimates for health expenditure and cardiovascular disease burden from 2022 to 2050 were extracted from published IHME datasets using established forecasting frameworks. As such, no independent forecasting was performed.^1,20, 21, 22, 23, 24 Health spending projections (2022–2050) were obtained from the Global Expected Health Spending 2018–2050 dataset, GDP projections (2022–2050) were obtained from the Gross Domestic Product Per Capita 1960–2018 dataset, population projections (2022–2050) were obtained from Global Fertility, Mortality, Migration, and Population Forecasts 2017–2100 dataset. Disease burden forecasts (2022–2050) were extracted from the GBD foresight visualisation tool under reference scenario.25, 26, 27, 28, 29 For regional aggregates, uncertainty intervals were propagated from country-level estimates using variance-based methods^30,31 (Supplementary Methods). Importantly, the long-term forecasts must be interpreted with caution as these estimates are based on scenario-based projections rather than precise predictions. These forecast tools are unable to fully represent transformative changes from future policy reforms, public health advancements, technological innovation, demographic shifts, climate change, macroeconomic or geopolitical shocks.²¹

Ethics approval

This study was exempt from Institutional Review Board review as it uses publicly available data that did not contain any confidential or identifiable patient information. All expert panel participants provided informed consent to participate in the consensus process.

Funding

This Commission is partly supported by funding from SingHealth Duke-National University of Singapore Cardiovascular Sciences Academic Clinical Programme, the National Medical Research Council of Singapore, and the Stafford Fox Foundation.

Role of the funding source

The funders had no role in the study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit the article for publication.

Results

Domain 1: Structure

System organisation

Most health systems in the Asia–Pacific region are centrally managed by Ministries of Health, which oversee governance and the development of CVD care guidelines.^6,32 However, Asia–Pacific's rapidly ageing population and the rising CVD burden emphasise the need for more efficient and integrated care systems.32, 33, 34 Currently, care delivery in the Asia–Pacific region remains fragmented, with weak linkages between primary and secondary or tertiary care hospitals, limited electronic medical record sharing, and under-resourced primary care for the management of cardiometabolic diseases,32, 33, 34 leading to challenges in achieving equitable, high-quality care in the region. The need for strategic expansion of digital health infrastructure, robust policy frameworks, and integrated data systems will be critical to addressing the demographic and epidemiological transitions ahead.^33,35,36 As such, delivering and strengthening a cohesive national CVD strategy and policy will be a key priority in informing countries to prioritise areas for reform. Nationally cohesive CVD strategies would ideally adopt a systemic whole-of-government approach, where Ministries of Health take the lead in collaborating with other sectors of government, thus ensuring horizontal and vertical integration of CVD policies across the government sectors.³² This will involve central-subnational coordination and policy implementation, addressing the care continuum from CVD prevention, early detection, treatment, to rehabilitation. While most countries (such as Australia, Japan, and South Korea) have a multi-ministry mechanism to tackle CVD, others lack multi-ministerial or equivalent coordination outside the Ministries of Health.³² Most countries in the region lack coordinating bodies or task forces between national and subnational governments, or between ministries, to prioritise and define ‘local’ CVD targets and subnational budgets that can achieve the national CVD strategy goals.³² Even in developing Asia–Pacific countries where health systems and inter-ministerial coordination are limited, promoting intersectoral action and Health in All policies (HiAP) can be incorporated within transformative economic and social development policies, which can effectively address underpinning health determinants. Opportunities exist for policies with shared economic, social, and health benefits, especially in LMICs—resource-constrained countries may strive towards HiAP strategies contextualised to the country's socioeconomic means and political will, integrating these policies at the level of a comprehensive development plan, and prioritising cardiovascular health as a shared goal of public policy.³⁷

Although many countries have NCD strategies that include CVD policies and programs, dedicated CVD strategies remain lacking in the majority of the Asia–Pacific region.³² This may result in the neglect of certain aspects of delivering CVD care, such as the lack of a clear pathway for collecting and evaluating existing CVD data to inform practical action plans to tackle CVD, especially in regions of the highest need.³² In high-income Asia–Pacific countries, CVD policies in diagnostics, acute and chronic care tend to be much stronger, while more work is needed to improve preventive and screening policies. Only a few countries, such as South Korea, have demonstrated strong central-subnational coordination in formulating, implementing, and reviewing evidence to refine CVD policies.³² South Korea's National Health Plan is a 10-year plan which requires all provincial and municipal governments to develop aligned local health plans for CVD prevention and management, to improve universal health standards and health equity.³⁸ Multi-sectoral partnerships in healthcare delivery, spanning governments and the private sector, will be crucial in ensuring adequate resources to address both commercial and social determinants of health.³² Multistakeholder engagement in the development of CVD policies should involve inter-ministerial coordination (involving finance, community, education, and health), intra-regional consultations (between central and subnational governments, and public-private sector partnerships), and key stakeholders (including patient groups) in the delivery of CVD policies.³² On the other hand, developing countries have focused their limited resources on preventive efforts (albeit uncoordinated to achieve CVD targets) rather than on effective CVD management.³² In these countries, successful stories in contextualising preventive cardiology strategies within the limits of the country's resources (e.g., Thailand's Universal Health Coverage model which ensures broad population coverage with the use of various public health insurance schemes),³⁹ can guide policymakers in designing context-specific strategies for promoting accessibility and sustainability in cardiovascular healthcare, through the use of polypills for key cardiometabolic diseases (e.g. “best-buys” for risk factors in LMICs),⁴⁰ manufacturing of good-quality generics, adopting cost-effective technological innovations, ensuring affordable health insurance systems for vulnerable populations, and improving home-based care and self-management.^40,41

Care delivery design

A care delivery value chain is a framework that outlines the activities required for the prevention and treatment of CVD. The importance of value creation within this chain lies in promoting coordinated care tailored to the needs of the local population, which utilises shared infrastructure to maintain long-term cardiovascular health. First, a key component in the Asia–Pacific would be to strengthen emergency medical services (EMS) and acute care services in CVD care to prevent premature morbidity and mortality. LMICs in the region are limited by poor capacity in emergency and acute care services, with limited step-down care services, and a lack of integrated care pathways. The lack of timely care is a predictor of unfavourable outcomes in acute cardiovascular events such as acute coronary syndrome. The time taken for primary percutaneous coronary intervention (PCI)—from onset-to-door time and door-to-balloon time—is crucial for improving long-term mortality rates. The national average door-to-balloon times for primary PCI were reported to exceed the recommended 90 min in China (134 min⁴²), Malaysia (110 min⁴³), Thailand (117 min⁴⁴), and Indonesia (97 min⁴³). The quality of EMS within the region will be critical to improving cardiovascular outcomes, including the provision of cardiopulmonary resuscitation (CPR) plans, early defibrillation, and average EMS response times. While countries such as India, Indonesia, and Vietnam have EMS in place, reports suggest that their coverage and capacity remain insufficient, adversely affecting response time and patient outcomes. Pre-hospital emergency services remain limited by inadequate EMS capacity. Current evidence demonstrates that pre-hospital rescue is often delayed in India, Indonesia, Vietnam, and Malaysia due to inadequate ambulance provisioning and shortages of trained emergency medical personnel.45, 46, 47, 48, 49, 50, 51, 52 In India, only 10.8% of patients with cardiac and stroke emergencies reach an appropriate level health facility within 1 h, contributed by multi-level upstream delays such as non-recognition of seriousness, transferring to an inappropriate facility, or lack of affordability.⁵³ Inadequate awareness of AED use in the public contributes to the acute gap in response to sudden cardiac events, with several countries (such as India, Indonesia, Thailand, and Vietnam) lacking formal community CPR training programs or responder networks to provide timely bystander CPR. Moreover, the public sector's insufficient acute care capacity, as well as the maldistribution of acute care services across cities and rural areas, pose challenges to the provision of acute CVD care. In Thailand, India, Vietnam, and Malaysia, the delivery of acute care is affected by the limited availability of the CVD workforce and inadequate acute care infrastructure, with the private sector in India contributing 60–70% of acute care services to make up for the gaps in public acute CVD care.^45,54,55 Governmental efforts are needed to strengthen emergency medical care networks and scale up good practices of acute CVD care, especially in LMICs.³² Considering the varied geographic and socioeconomic conditions in India, a “hub and spoke” model has been utilised to deliver acute coronary syndrome care, primarily focused on timely thrombolysis to expand the reach of reperfusion therapy in smaller cities with limited resources.56, 57, 58

Second, strengthening screening and diagnostic guidelines, as well as capacity for early risk factor detection, will be vital for CVD care delivery.^59,60 Hospitalisations from acute cardiovascular events are a significant driver of healthcare costs. In Australia, CVD hospitalisations and emergency services at public hospitals accounted for USD 3.7 billion from 2019 to 2020, nearly half of all government spending on CVD.⁴⁶ Reducing hospitalisations through earlier detection and management of CVD risk factors will be integral to tackling the rising CVD burden.^32,61,62 Holistic national strategies for CVD management should encompass collaborative, multistakeholder efforts led by health ministries that address the entire care continuum—from prevention to integrated health systems focused on early detection, primary care, tertiary care, and rehabilitation.³² However, in some countries, there is a lack of up-to-date national screening and diagnostic guidelines aligned with global best practices. Screening guidelines and programs for hyperlipidaemia are reportedly lacking in China, India, Malaysia, Thailand and Vietnam,^32,47,48 which should be strengthened at the primary care level.³² Similar studies have demonstrated a need for improved detection and treatment of hypertension in primary care in China, India, Malaysia, and Thailand.63, 64, 65, 66, 67 The inadequate screening of cardiovascular risk factors within communities is multifactorial, attributed to the shortage of front-line community health workers and allied health workers in India, Indonesia, Malaysia, and Vietnam.^32,49, 50, 51 In India and Malaysia, the screening of risk factors is dependent on volunteer community workers who are often not compensated proportionally,^52,68,69 and have limited accountability, resulting in gaps in coverage and loss to follow-ups across population groups.^69,70 There are varying gaps in coverage and uptake of cardiovascular screening and diagnostic services, especially in rural regions and high-risk population.^71,72 Poor uptake in screening services was observed in high-risk groups, especially in elderly individuals in Indonesia, and lower socioeconomic population groups in India and Malaysia.^73,74 In addition, diagnostic capacities and infrastructure are often found to be maldistributed, lacking in rural and remote regions,³² and concentrated in urban centres.³² In terms of secondary prevention, strategies to strengthen diagnostic capabilities, leveraging evidence-based cardiac biomarkers such as high-sensitivity troponin and natriuretic peptides, can be beneficial for earlier detection of CVD and timely interventions.^32,75,76 However, the use of these biomarkers is often limited to the private sector, given high out-of-pocket costs and high clinical inertia in specific regions of India, Indonesia, and Vietnam.³²

Third, there is a need to prevent rehospitalizations by improving cardiac rehabilitation (CR) services. This can be achieved by developing national guidelines for CR, establishing referral pathways, accrediting services, and ensuring the use of updated policies and adherence to guideline-directed medical therapy. Robust CR care capacity is essential to promote continuity of care outside clinical settings, within the community, and at home.⁷⁷ Home-based CR programs can be cost-effective, especially for populations with reduced mobility, such as those from rural areas and indigenous groups, by overcoming access barriers, including travel time, missed work, and caregiver burden. However, globally, 71·6% of all CR programs were delivered in urban regions, while 14·3% and 12·4% of cardiac rehabilitation services were delivered in suburban and rural areas, respectively.³² Vietnam and Thailand's CR programs covered less than 0·5% of new IHD cases in 2019,⁷⁸ while Malaysia had more patients participating in CR than programs could accommodate.³² System-level barriers, such as inadequate post-discharge patient referrals, as well as financial and human resource constraints, have hindered CR delivery, especially in rural areas of Australia, China, and Malaysia. Thus, health systems need to deliver sufficient program density per given number of CVD patients in the country³² allocating adequate funding for affordable public rehabilitation programs, especially in rural regions.^79,80 CR will be key to cost-effectively reducing the CVD burden by promoting medication adherence and improving lifestyle factors, which can be facilitated by incorporating remote monitoring technology and promoting tele-rehabilitation. In Beijing, the smartphone-facilitated home-based CR (HBCR) model was established for patients with ischaemic heart disease following successful revascularization, providing weekly educational material and tailored exercise prescription, leading to nearly six-fold reductions in major adverse cardiac events and unscheduled readmissions compared to those who did not receive HBCR.⁸¹ Moreover, culturally acceptable and contextually relevant CR programs that use local forms of exercise, such as yoga-based CR,⁸² may be effective models for improving CR uptake among specific subgroups (e.g., women and the elderly), self-rated health, and return to pre-infarct activities in India.⁸²

Fourth, policies are needed to tackle the rising cardiometabolic epidemics through comprehensive multi-sectoral policy changes and awareness programs. Multi-sectoral approaches, incorporating interconnected preventive strategies across healthcare, education, urban planning, and food systems, will be crucial for addressing the synergistic effects of cardiometabolic risk factors. Many countries in the Asia–Pacific have failed to meet targets for a healthy diet and/or obesity prevention. In China, Malaysia, Thailand, and Vietnam, childhood obesity has more than doubled in the last decade.83, 84, 85 India, China, and Indonesia are projected to have the first, second, and fourth largest prevalence of childhood obesity by 2030.⁸⁶ This is parallelled by the most significant rise in sales of ultra-processed foods in Asian countries between 2009 and 2019, with the highest in India (7·8%), Pakistan (6·3%), and Indonesia (4·5%), compared to Western counterparts (0·4% in the US).⁸⁷ Comprehensive, multi-sectoral policy changes and awareness programs can strengthen obesity screening and management programs to address the surge in childhood obesity. This can be achieved by reformulating processed foods and snacks within healthy limits, improving access to fruits and vegetables, and promoting physical activity in the workplace, public areas, and the community. A prime example of partnerships across government, public, and food sectors is the Centre for Indonesia's Strategic Development Initiatives implemented taxation of sugar-sweetened beverages (with a consequent 20% increase in prices), leading to reductions in sugar consumption by 17·5% while generating additional income for the ministry to reinvest in these policies.⁸⁸ In terms of strategies to improve physical activity, Singapore has implemented mobile-based physical activity programs through the National Step Challenge, which provided step trackers to participants and recorded their daily physical activity, pairing step count goals with financial rewards.⁸⁹ This programme has reported that the mean daily step count increased by 1579 steps per participant.^90,91

While there are shared challenges between LMICs and high-income countries, including fragmented specialised (siloed) programmes and competition for finite resources, the care delivery value chain priorities may differ between the two sets of countries (Fig. 1).³ In LMICs, value creation in CVD healthcare delivery tends to be more narrowly (vertically) focused on episodic, curative services at the point of delivery, rather than integrated chronic disease management.⁹² This is contributed to by a lack of infrastructure, essential medicines, and trained personnel needed for comprehensive CVD care. For example, a study in Kazakhstan found its primary focus to be tertiary CVD care rather than primary or secondary prevention, resulting in missed opportunities for prevention, early diagnosis, and effective long-term follow-up. Beyond improving the uptake of priority CVD services, LMICs aim to gradually achieve universal health care coverage while concurrently enhancing the efficiency of healthcare delivery. In contrast, the focus of high-income countries is to improve care delivery by investing in systemic enablers such as governance, financing, planning, and information systems, as well as developing multi-sectoral collaborative models that involve multidisciplinary team efforts to manage the needs of the ageing population with multiple morbidities and/or complex cardiovascular needs.³ High-income countries have a stronger focus on changing patterns of healthcare use (i.e., shifting from inpatient CVD care to primary and community care), with a growing emphasis on improving the individual patient experience and quality of care while lowering overall healthcare costs.³ The highly diverse health systems, socioeconomic and political developments across and within countries of the Asia–Pacific, exacerbated by the demographic and epidemiological transitions taking place at among the fastest rates relative to other regions,³² intensify the existing challenges faced by both sets of countries. As such, this emphasises the critical need for Asia–Pacific communities to connect and initiate dialogues on sharing methods and knowledge across income settings—for example, useful lessons can be learnt from high-income countries' integration initiatives, care planning, and service delivery that might enhance continuity of patient-centred care in LMICs, while high-income countries can learn from LMIC experiences in expanding specialised healthcare practitioners’ skills in providing more holistic services through inter-professional education and collaboration practice.⁹³

Fig. 1.

Shared and distinct challenges in care delivery value chain priorities between low-to-middle income countries and high-income countries in the Asia–Pacific. HICs, high-income countries; LMICs, low-to-middle income countries; EMS, emergency medical services; CPR, cardiopulmonary resuscitation; CV, cardiovascular.

Financing

Financing is a key determinant of equity, access, and sustainability in health systems. Despite moderate improvements in regional cardiovascular morbidity rates, health expenditure (as a proportion of the country's gross domestic product [GDP]) has risen by 1·6% from 1990 to 2021. This rising trend is set to persist, with a projected 1·9% increase from 2025 to 2050, primarily driven by rising proportions of government and out-of-pocket expenditure, while other healthcare financing sources, such as DAH, will remain unchanged (Supplementary Figure S2).94, 95, 96 There is significant heterogeneity in the sources of health spending across the region's health systems. In countries with the poorest healthcare access and quality performances (i.e., first and second deciles of the HAQ Index), a large proportion of health spending was dependent on DAH. In contrast, health spending in countries within the middle deciles of the HAQ Index was primarily contributed by out-of-pocket spending. A summary of the components of healthcare expenditure is included in Supplementary Table S3.

On the other hand, in countries with the highest healthcare access and quality performance (i.e. ninth and tenth deciles of the HAQ Index), government health expenditure accounts for the highest proportion of healthcare spending (Fig. 2). A key contributor to health inequities across the region is the significant disparity in health spending capabilities. Countries with lower healthcare access and quality performances (i.e. first to fifth deciles of the HAQ Index) contributed to less than 15% of the total health spending in the Asia–Pacific. Yet, these countries account for more than 50% of the region's total population and bear nearly 50% of the region's total CVD morbidity burden in 2021 (Fig. 3). Among countries with similar health spending (i.e., contributing to 0·01–0·1% of the region's total health spending), those with higher healthcare access and quality performances (i.e., Maldives and Brunei) faced substantially lower burden of CVD morbidity, compared to those with poorer health system performances (i.e. Laos and Papua New Guinea). The disparate trends in health spending and CVD outcomes are evident in the Asia–Pacific, with higher income countries (i.e. Japan and Republic of Korea) having the highest healthcare expenditure per capita (primarily contributed by government health expenditure) and observing the lowest CVD burden, while lower income countries (i.e. Kiribati and Tuvalu) with the lowest healthcare expenditure per capita (contributed substantially by DAH and government health expenditure) bear the highest CVD burden in the region in 2021 (Fig. 4 and Supplementary Figure S3).

Fig. 2.

Health expenditure sources across the HAQ Index. The proportion of health expenditure sources in the Asia–Pacific, stratified across the healthcare access and quality (HAQ) Index deciles. The health expenditure sources were development assistance for health (DAH), prepaid private health expenditure, out-of-pocket spending, and government health expenditure. The solid line represents the age-standardised cardiovascular disease disability-adjusted life year (DALY) rate (per 100,000) from 1995 to 2021, and the dashed line represents the projected age-standardised DALY rate (per 100,000) till 2050.

Fig. 3.

Share of total health expenditure, DALYs, and population by HAQ Index decile. The shares of total health expenditure, cardiovascular disease disability-adjusted life years (DALYs), and population size, stratified by each healthcare access and quality index (HAQ) Index decile in the Asia–Pacific (top). The distribution of countries across the share of total health expenditure and total DALYs (bottom).

Fig. 4.

Healthcare expenditure as a proportion of gross domestic product (GDP) and healthcare expenditure per capita across each country in the Asia–Pacific. (A) Healthcare expenditure as a proportion of GDP, including the source of healthcare expenditure, per country. The line represents the cardiovascular disease age-standardised disability-adjusted life year (DALY) rate (per 100,000 population). (B) Health expenditure per capita, including the source of healthcare expenditure, per country. The line represents cardiovascular disease age-standardised DALY rate (per 100,000 population).

Public financing dominates in high-income countries, providing free or subsidised primary and secondary care with broad benefit coverage.^95,97 By contrast, LMICs rely heavily on a mix of government subsidies, social insurance schemes, and out-of-pocket payments. In upper-middle-income countries such as China, Vietnam, and Malaysia, social health insurance expansion has increased coverage, but gaps persist in outpatient services, particularly for rural populations.^96,98,99 Low-income countries and some Pacific Island states are also dependent on external donor funding to sustain healthcare services, creating vulnerability to shifting donor priorities and service volatility^95,97; as a result, the risk of excessive spending rises with increased out-of-pocket expenditure in low-income countries.¹⁰⁰ For example, India has one of the highest out-of-pocket health spending, exceeding government health spending, which was one of the lowest in the Asia–Pacific, and has low social health insurance coverage relative to other countries in the region.^32,101 Out-of-pocket expenses have been reported to exceed the recommended threshold of 20% in China, India, Indonesia, Malaysia, South Korea, and Vietnam, with higher out-of-pocket costs among low socio-economic status households and older individuals with multimorbidities.¹⁰² As systems with comprehensive universal health coverage can still incur substantial out-of-pocket expenditures, suitable financial coverage for complex treatments should be provided in high-risk populations.³² Moreover, caregiver responsibilities primarily lie with families in the Asia–Pacific, compared to regions where long-term rehabilitation in an assisted living facility are more common, evoking added psychosocial costs (including stress, depression and social exclusion that hinders full participation in day-to-day activities)³² and indirect costs of CVD to the economy (including absenteeism, loss of workplace productivity, informal caregiving costs, and welfare payments)³² which have exceeded direct healthcare costs. For instance, in Indonesia, the percentage of IHD-related productivity loss due to absenteeism and presenteeism was approximately 2·8% and 6·8% of GDP per year, respectively, in 2018.¹⁰² This amounted to indirect costs of USD33·3 billion attributed to loss of productivity, and USD139 billion in healthcare costs, by retirement age.¹⁰²

As a region, the average healthcare expenditure per capita in the Asia–Pacific (USD 505) was lower than the global estimate (USD 1324) in 2021, and this trend is likely to persist beyond 2025. Healthcare expenditure per capita in high- and high-middle SDI Asia–Pacific countries will be above the region's average health spending per capita. In contrast, low-to middle-SDI Asia–Pacific countries are expected to observe lower healthcare expenditure per capita than the region's average estimates (Supplementary Figure S4). Despite having the lowest health spending per capita, low-to middle-income SDI countries will bear the greatest share of the region's CVD burden (Supplementary Figures S5 and S6). The region must grapple with the rapid economic and demographic change, which has seen 55% of the global consumer class in the Asia-Pacific.^32,103 The growth is characterised by rapid urbanisation, in which Southeast Asia's urban population has increased from 32% to 50% between 1990–2020,¹⁰⁴ resulting in increased demand for healthcare delivery, health spending, and caloric intake, and widening disparities in access to healthcare and public services between urban and rural regions. Moreover, the pace of population growth and ageing in the Asia–Pacific has surpassed that in Europe and the US.¹⁰⁵ High-income countries, such as Japan and South Korea, have observed rising CVD hospitalisations and high healthcare expenditure in rapidly ageing societies.^21,32,106 Upper middle-income countries, such as China and Thailand, are facing similar challenges in ensuring fiscally sustainable health systems while addressing the growing CVD burden of an ageing population. CVD policy implementation requires government commitment to adequate spending on CVD care; however, financial risk protection against excessive expenditure is equally important to ensure timely access to CVD care without pushing patients into poverty.³²

Quality infrastructure

Quality of care refers to the extent to which health services for individuals and populations increase the likelihood of desired health outcomes.¹⁰⁷ Several domains of quality will be discussed (Supplementary Table S4). First, strengthening critical enablers of CVD care in the Asia–Pacific can be achieved through enhancing monitoring and evaluation systems of health system capacity, auditing clinical adherence to guidelines, CVD procedural-related outcomes, and overall health system performance, and enabling digital health transformation and innovation. The monitoring of clinician adherence to evidence-based CVD practices has been reported as challenging in Indonesia and Vietnam, and there is a lack of audits to track clinical adherence in private hospitals and healthcare facilities in Thailand and India.³² Nevertheless, health authorities can leverage existing major registries, such as the PINNACLE India Quality Improvement Program (PIQIP) in India and the National Cardiovascular Data Registry (NCDR) in Pakistan, to guide risk initiatives and quality improvement projects and benchmark against international standards.108, 109, 110 However, registry coverage and data quality remain limited by financial constraints, fragmented infrastructure, and inconsistent regulatory mechanisms. Barriers include a lack of budget, poor data management, low stakeholder motivation, and technological limitations.111, 112, 113 Most registries remain procedure-based, with variable integration and inconsistent definitions, and only a few countries have developed comprehensive, multi-domain cardiac registries.^112,114,115 In Japan, the Japanese Registry of All Cardiac and Vascular Diseases (JROAD) and the Japanese PCI registry (J-PCI) are national registries that collect clinical data from a substantial number of hospitals countrywide.¹¹⁶ This data has been used for benchmarking, research, and eventually the development of policies to improve healthcare efficiency and outcomes.^117,118 Registries in Thailand, Malaysia, India, and Indonesia have been reported to lack good data governance in maintaining up-to-date information, while data collection and practices have been described as voluntary in Malaysia.32, 33, 34 Establishing national CVD registries and enabling linkages with electronic medical records accessible to public and private healthcare providers would enable more timely and comprehensive evaluation of patient CVD data, guiding data-driven policy changes. Regulatory bodies that can enforce annual audits of health capacity and delivery—including the availability of healthcare staff, pharmacotherapeutics, and equipment; adherence to guideline-directed practices; and distribution of health services across rural-urban areas—will be important for enabling optimal CVD care performance and health systems.³²

Second, the CVD care capacity in the Asia–Pacific is limited by poor workforce development planning, a lack of research and development in cardiovascular medicine, and ineffective monitoring and evaluation practices for auditing health system performance.³² Workforce recruitment and retention strategies can strengthen CVD care capacity across the continuum, including professional support programs, mentorships, and scholarships with service bonds.³² The majority of Asia–Pacific countries are challenged by the shortage of skilled health workforce capacity in providing CVD care, with 1) most reporting a shortage of CVD specialists in the public sector and rural areas (cardiologists are concentrated in cities and metropolitan areas of China, Thailand, Japan and South Korea, with shortage in rural health services); 2) insufficient community physicians at the primary healthcare level in India, Malaysia and Vietnam; 3) lack of frontline workers performing screening in Malaysia, India, Indonesia and Vietnam; and 4) inadequate skilled diagnostic technicians in China, Australia, India and Vietnam in providing diagnostic imaging services.³² The workforce shortages are exacerbated by the maldistribution of the skilled workforce in the Asia–Pacific, across the rural-urban divide, with decreasing public health workforce retention. The retention of specialists in public healthcare has reportedly been low in Malaysia and India, attributed to high workloads, limited budgets, and greater career progression opportunities and financial incentives in the private sector.119, 120, 121 In Malaysia and China, there is a need to address barriers to specialisation³² while in South Korea, Japan and Australia, efforts are needed to improve working conditions to enhance workforce retention.^122,123

Third, the heterogeneity of countries' socioeconomic development, cultures, and natural environments has contributed to substantial differences in digital healthcare adoption across the region. While most countries have national strategies to implement digital health in CVD care, uptake has been mixed across healthcare settings.³² Barriers impeding its uptake are multifactorial. In higher-income countries, these include poor interoperability across health information systems, which limits CVD patient data transmission between referral levels (e.g., cardiac units and primary care providers).¹²⁴ In LMICs, the challenges are often more foundational, including a lack of the expertise, skills, infrastructure, and digital literacy required for widespread digital health adoption.³² National health authorities should develop a roadmap for building digital infrastructure to support a digital cardiovascular service ecosystem in the Asia-Pacific.³² This would involve developing a hybrid digital cardiology service model for patient care, creating digital roadmaps to enhance digital innovation, establishing operational guidelines for digital cardiology services, and upskilling healthcare staff in digital literacy.³² As digital health evidence for cardiovascular outcomes is constantly evolving, the Asia–Pacific must prioritise implementation science with the goal of driving cost-effective and scalable artificial intelligence-driven workflows for precision prevention, that address the region's unmet translational needs. Robust surveillance and regulation are necessary to ensure these tools do not further perpetuate existing health care inequalities in the region.¹²⁵

Domain 2: Process

Access

Regional context

There is substantial heterogeneity across Asia–Pacific countries in the accessibility of cardiovascular healthcare services. Cost-effective preventive interventions have been successfully deployed in high-income Asia–Pacific countries to kerb the CVD epidemic; however, such treatments are largely missing in at-risk populations, particularly in most LMICs.¹²⁶ Treatment gaps in secondary prevention have seen the underuse of aspirin, blood pressure-lowering therapies, and statins in most LMICs.^126,127 These inequalities exist between and within countries, with studies demonstrating that in rural Andhra Pradesh, India, less than one-sixth of individuals with prior atherosclerotic CVD received antiplatelet therapy,¹²⁸ and only two-thirds of the diabetes population received glucose-lowering therapy.¹²⁹ These treatment gaps are complex, and reflect inadequate implementation of guideline-directed medical therapy related to patient, doctor and health system barriers, poor treatment adherence attributed to treatment cost and budgetary constraints, and social stigma associated with long-term medical use.^130,131

Implementation of accessible primary preventive care in LMICs will require concerted efforts to prioritise scarce resources for cost-effective, culturally appropriate, and sustainable interventions.¹³² The rapid deployment of effective CVD prevention strategies already proven in high-income Asia–Pacific countries could be tailored for LMICs, with attention to affordability, effectiveness, accessibility for disadvantaged groups, and the burgeoning middle classes.¹³⁰ Evidence-based clinical strategies in CVD prevention and management, complemented by evidence-based population strategies, such as legislation in controlling tobacco use through taxation and advertisement restrictions,^130,133 can prove to be effective. Furthermore, effective primary healthcare in LMICs requires major changes in organisation and resource management, shifting away from providing episodic care (i.e., catering to infectious diseases and injuries) to continuing care (i.e., prioritising CVD and other NCDs). Well-functioning primary care services can improve access, lower costs, and enhance CVD outcomes in LMICs by expanding access to preventive care and early CVD treatment for deprived populations, and by avoiding costly specialist and hospital treatment (Box 2).^130,134

Case study

Healthcare access challenges faced by some of the world's largest populations are exemplified in rural China, with a decline in access to healthcare for rural areas. This is underscored by growing healthcare costs, poor insurance coverage, and limited public funding.¹³⁰ Furthermore, the health system in China is oriented towards hospital-based care and treatment, as clinicians are generally paid according to services provided, with commissions from medication sales forming a significant component. Such incentives can drive high-cost and overtreatment, contributing to increased barriers to primary healthcare services and preventive strategies, especially in rural populations.^130,135 Over time, public expectations have transformed, driven by awareness of advanced medical technology and a preference for hospital treatment for basic medical conditions.¹³⁵ This highlights a key challenge for the Chinese government: implementing policy changes to address the mismatch between patient expectations and primary care workforce capacity by increasing the skills of primary healthcare providers and improving access to quality CVD prevention. Upskilling primary healthcare providers in rural regions, augmented by the implementation of effective referral systems to hospitals for cardiovascular specialist care, would be the way forward. The cost of screening and preventive treatment could be reimbursed through the Cooperative Medical Schemes, a system of social health insurance in China, that primarily covers hospital care.¹³⁶ Implementation of low-cost CVD surveillance programs could be beneficial in evaluating the progress of primary healthcare practice, especially in resource-poor, rural settings,¹²⁸ promoting healthcare delivery research in rural China, improving transparency in the setting of prioritising resource allocation,¹³⁰ and gearing health investments towards the best buys based on cost-effective evidence in CVD prevention.

Equity

Regional context

The inverse care law describes socially disadvantaged communities with the highest cardiovascular risks receiving the poorest access to adequate treatment.¹³⁷ Despite the emergence of novel metabolic pharmacotherapies, the treatment-risk paradox remains prevalent in the Asia–Pacific, with high-risk, marginalised populations less likely to be covered by national health plans, to make substantial out-of-pocket payments, and to receive these novel pharmacotherapies.^97,138, 139, 140, 141 These prohibitive costs of essential CVD therapies can distort patients' care decisions and limit management.142, 143, 144 This has driven low rates of anticoagulation therapy in individuals with atrial fibrillation for stroke prevention,^145,146 and low treatment adherence among patients with coronary heart disease in LMICs.^147,148 Government revenue raising and expansion of fiscal space to facilitate healthcare spending^149,150 can help lessen financial constraints in achieving universal health coverage in Asia–Pacific countries.¹⁵¹ There may be a role for government-provided universal health insurance, which increases equity with a trade-off in efficiency.¹⁵² Such a model has been implemented in Thailand, where the government launched a universal coverage program in 2001 by expanding government-funded health coverage to uninsured citizens and limiting out-of-pocket payments to 30 Baht per encounter, eventually eliminating them by 2006.^95,153 This reduced financial barriers to access for the poor, with every Thai citizen now entitled to essential preventive and curative CVD care services at all life stages. However, national health expenditure is heavily borne by the government, as these policies face challenges in containing rising costs amid rapid changes in the ageing population and disease profiles, with Thailand's aim now to enhance and sustain its universal health coverage policy.³⁹ Adequate investments in promoting universal primary healthcare can be an effective way to strengthen equitable cardiovascular care, ensuring timely referrals to secondary and tertiary cardiovascular services for those most in need, resulting in less fragmented health system, boost community engagement, and reducing private health spending in disadvantaged populations.^154,155

In addition to the region's socioeconomic inequities and wide gaps in access to healthcare, an eclectic mix of psychological, ethnic, and sociocultural barriers exists to the delivery of equitable cardiovascular care for women in the Asia-Pacific.^156,157 The low awareness of CVD risk among women in the Asia–Pacific has been attributed to limited education, cultural beliefs, and misconceptions. For example, a Singapore population survey reported that only 10% of women in Singapore were aware that CVD is the leading cause of mortality for Singaporean women, while only 8% discussed their cardiovascular health with their practitioner in the past 1 year.¹⁵⁶ A substantial proportion of women in the Asia–Pacific living with CVD distrust allopathic medicine, and prefer their homes as the place of death rather than hospitals; thus, the cause of death is often misclassified as old age.¹⁵⁶ Cultural and religious beliefs play an essential role in setting expectations for women to be caretakers of health and for men to be decision-makers about medical care.¹⁵⁶ Moreover, traditional roles in domestic duties and employment, compounded by environmental factors (e.g., hot weather) and religious expectations, may limit women's engagement in physical activity.¹⁵⁶ Disparity in quality of care has influenced poorer survival in women following acute coronary syndrome in the Asia-Pacific.¹⁵⁸ This is contributed to by a myriad of sex-based disparities, including underestimated risk perception, prolonged time to presentation,¹⁵⁸ delayed time to perfusion therapy,¹⁵⁸ reduced access to angiography and angioplasty, and suboptimal guideline-directed medical therapy prescription practices in women compared to men when presenting with symptoms of acute coronary syndrome.158, 159, 160 Furthermore, as women from the Asia–Pacific remain under-represented in clinical trials, further efforts are warranted to increase women's involvement in clinical trials, reporting of sex-ethnic specific cardiac outcomes, and including the wider social determinants of health that can inform guideline recommendations for the enhanced CVD care delivery for Asia–Pacific women.¹⁵⁸

Low health literacy and education in disadvantaged populations within the region can also impair cardiovascular health, and social inequity can pose an intergenerational health impact.^161,162 Education standards vary widely across the Asia–Pacific region, with <70% of the population completing primary education in some countries. Marginalised populations and stateless groups may face further barriers arising from their residency status, with a lack of access to available healthcare financing solutions compounded by low health literacy and poor familiarity with local health systems.163, 164, 165 Improving health literacy promotes self-care, quaternary prevention, adherence to complex cardiovascular treatment, and informed patient co-responsibility and engagement in healthcare.¹⁶⁶

Case study

In 2006, the Adult Literacy and Life Skills Survey found that only 40% of Australians had a ‘sufficient’ level of health literacy.¹⁶⁷ A national push towards improving health literacy was initiated by the Australian Commission on Safety and Quality in Health Care, which coordinated a “National Statement on Health Literacy” in 2014,¹⁶⁸ outlining how various stakeholders (consumers, healthcare providers and policymakers) could work together to promote health literacy. This was endorsed and subsequently translated into concrete strategies by regional administrators in New South Wales,^168,169 Northern Territories,¹⁷⁰ Tasmania,¹⁷¹ and Queensland.¹⁷² Education about health, development, and healthcare was incorporated into the national curriculum from preschool up to secondary school under the ‘health and physical education’ pillar.¹⁷³ This was further supplemented by in-school health education delivered by not-for-profit providers such as the ‘Healthy Harold’ program run by Life Education Australia. Accordingly, the 2018 National Health Literacy Survey showed improvements across the board, with 91% of respondents agreeing that they could manage their health.¹⁷⁴ Efforts are underway to refine these strategies, with the Australian government in the midst of developing the National Health Literacy Strategy¹⁷⁵ as part of the National Preventative Health Strategy 2021–2030.

Efficiency

Regional context

Incorporating innovative digital health solutions to provide CVD care (i.e. mobile health and telemedicine) can enhance CVD care efficiency and cost-effectiveness in the Asia–Pacific. Digital clinical decision support systems have the potential to deliver efficient CVD care, especially in resource-poor regions with large populations or extensive geographical areas.¹⁷⁶ The applications of telehealth range from medical services (such as diagnosis, treatment, remote prescribing, and continuity of care) to ancillary services (such as payments, physician selection, patient education, healthcare records, and reminders), all of which enhance the efficiency of healthcare delivery. The SimCard Randomised Trial examined a simplified, guideline-based, multifaceted intervention program for cardiovascular management, delivered by community health workers, using a mobile technology-based electronic decision support system, in a population of individuals with high cardiovascular risk in rural China and India.¹⁷⁷ The smartphone-based intervention arm demonstrated a 25·5% increase in the proportion of patients reporting antihypertensive medication use, with improvements in systolic blood pressure following intervention, compared with the control arm at 1-year follow-up.¹⁷⁷ Even in developing countries with scarce resources, internet access and mobile phone use among adults are nearly universal in the Asia–Pacific region^178,179; hence, health policies should incorporate customised mobile technology to improve the quality of CVD care at the primary care level in remote areas with limited resources. Telemedicine services can also facilitate large-scale virtual patient flow from poorer to more resource-rich areas, as patients can be diagnosed and treated electronically by healthcare providers based in resource-rich locations.¹⁷⁶ Thus, telehealth as a medium of CVD care delivery can be beneficial for interregional support, especially in LMICs with large populations, such as Indonesia, the Philippines, and Bangladesh, where top-ranked cardiovascular care hospitals are located in the three main cities of each country.180, 181, 182 Although the usage of telehealth reflects the access to care for CVD patients, more work should focus on regulation, quality, and digital literacy by ensuring the care delivered aligns with contemporary evidence and examining whether clinical outcomes are improved.¹⁷⁶

Case study

The Chinese State Council has established the Internet Plus Action Plan in 2015 and the Internet Plus Healthcare in 2018 to adopt mobile health, a method of telemedicine delivery via mobile applications between healthcare providers and patients, focused on key functions such as diagnosis support, treatment, rehabilitation, and education.^183,184 The trend of telemedicine has grown in China from 2016 to 2020, with hospitals recording a 10·7% annual growth rate in telehealth services.¹⁷⁶ Disparate distributions of telemedicine health applications geographically and socioeconomically exist within China, with the two provinces with the most hospitals accessible via telemedicine having the highest GDP per capita. Nevertheless, provinces with the lowest GDP per capita had the highest growth rates in the number of hospitals accessible via telemedicine applications.¹⁷⁶ While private (66·5%) and primary hospitals (34·6%) constituted the majority of medical institutions in China in 2020,¹⁷⁶ the ratio of telemedicine usage was reversed, with public and tertiary hospitals being the key providers. There is significant capacity to expand primary care facilities and private hospitals for diagnosing and treating common CVDs using telemedicine.¹⁷⁶

Effectiveness

Regional context

Despite this push towards standardising best practices, adherence to guidelines remains varied within¹⁸⁵ and between Asia–Pacific countries¹⁸⁶ resulting in disparities in outcomes.^180,187,188 Both guideline complexities and resource constraints contribute to the evidence-practice gap.¹⁸⁹ Furthermore, the majority of the Asia–Pacific countries continue to use clinical practice guidelines developed for the US or European populations. Local clinical practice guidelines are updated every 2–5 years in most countries in the region, with some (e.g., Malaysia) enforcing updates more than 5 years apart.³² However, genetic differences and the epidemiological transition in the Asia–Pacific emphasise the need to tailor CVD strategies to local populations by advancing national research, development, and innovation (RDI) capabilities.³² Regionally developed CVD risk assessment tools, such as the Japan Atherosclerosis Society Guidelines and the China-PAR (Prediction for ASCVD Risk in China) risk model, allow healthcare professionals to tailor strategies to local epidemiology and risk factor patterns.190, 191, 192, 193, 194 In 2025, the SCORE2 Asia–Pacific model was calibrated to provide 10-year risk estimates for CVD in apparently healthy people in the Asia–Pacific, enabling better-targeted prevention strategies in the region.¹⁹⁵

There is a need for targeted “best buy” population-based intervention strategies, such as implementing legislation, for cost-effective reduction of cardiovascular risk factors (tobacco use, salt intake, excessive alcohol consumption).^196,197 These population-based modifiable behavioural risk factors account for a substantial proportion of the total cost of the “best buys”.^196,198 In LMICs within the region, the most effective “best buy” interventions are taxation on tobacco products, sugar-sweetened, and alcoholic beverages.¹⁹⁶ Taxation on tobacco products is the most direct way to increase its cost and reduce its demand.¹⁹⁷ Moreover, close partnerships between Asia–Pacific countries can be a vital asset for advancing cardiovascular health in the region by sharing knowledge, resources, and successful evidence-based CVD preventive strategies. The successes of the sin tax models in Thailand and the Philippines have served as models for India's 2025 sin tax reform,¹⁹⁹ highlighting the opportunities of open communication, exchange of ideas, and implementation of proven cardiovascular preventive models within the region.

Case study

The Philippine government implemented tax reforms on all tobacco and alcohol products in 2012, leading to an effective reduction in tobacco use from 30% in 2009 to 24% in 2015.²⁰⁰ The average household cigarette consumption decreased from 62 packs in 2009 to 52 packs in 2015, with tobacco taxation accounting for 70% of the reduction.²⁰⁰ In 2018, the “sin tax” extended to include sugar-sweetened beverages.²⁰¹ Additional revenue from the “sin tax” was used to fund other universal healthcare programs, especially in poor and disadvantaged communities in rural regions,²⁰⁰ with the Philippines Department of Health budget increasing from USD 1·1 billion in 2013 to USD 3·2 billion in 2019, with 55% of the total budget contributed by “sin tax”.²⁰²

Care continuity and coordination

Regional context

Continuity of care and coordination is integral in providing sustainable CVD management, which includes longitudinal care, stable patient-healthcare worker relationships, and effective coordination of services.203, 204, 205, 206 The implementation of continuity of care has been associated with improved cardiovascular outcomes, fewer complications, increased utilisation of health services, and higher quality of life.^207,208 However, many developing countries in the region face challenges in providing effective continuity of care, especially in fragmented, diverse health systems^92,209,210 with limited access to primary healthcare facilities.211, 212, 213 The effectiveness of continuity of care in LMICs can be influenced by low levels of patient health literacy and the availability of healthcare providers.²¹⁴ On the other hand, high-income Asia–Pacific countries face fragmented electronic health record systems with limited interoperability, funding and regulatory obstacles215, 216, 217 and additional barriers posed by stringent governance and excessive security policies.²¹⁸

To address these challenges, community-based care models must be supported by educational strategies and social support programs tailored to the cultural contexts and literacy levels of different Asia–Pacific populations. These approaches should engage families and community healthcare providers as active partners in long-term care, and healthcare policy reforms should focus on more integrated care systems between primary care and specialised cardiovascular facilities, while strengthening health insurance policies that sustain long-term care accessibility for older adults living with CVD.²¹¹

Case study

Empanelment increases accountability of care for each individual and promotes continuity of the provider-patient relationship in the management of CVD. This strategy is adopted in the Healthier SG²¹⁹ in Singapore, which provides a comprehensive framework to streamline coordination and continuity of care. It mobilises existing networks of private family-care physicians alongside government-controlled polyclinics to facilitate enrolment of residents with named primary care physicians to create personalised care plans and follow up. These policies are incentivised by government-provided subsidies and supported by digital aids. To facilitate clinical data sharing, the National Electronic Health Record was developed in 2011 as a central repository for patient data, including information on discharge summaries, clinical investigations, medication prescriptions, immunisations, and upcoming appointments.²²⁰ A derivative, patient-facing application (HealthHub) was created to present concise information to patients on test results and upcoming appointments, provide digital payment collection, and send reminders via push notifications. Healthier SG also encourages local stakeholders to work together to engage the local community, such as eldercare facilities and community centres that organise healthy physical activities.²¹⁹ By integrating these service providers into broad regional health management clusters with specific geographical remits, organisations within the community can work together to share data on local residents and onboard them to beneficial programmes.

Patient-centeredness

Regional context

With the diverse socio-cultural milieu of the Asia–Pacific, recognition and implementation of patient-centred care vary across the region. Evidence of patient-centred care models in LMICs remains limited,²²¹ while shared decision-making in cardiovascular care is common in high-income countries.^222,223 Quality communication and joint decision-making improve patient satisfaction, treatment adherence, and cardiovascular outcomes.²²⁴ Culturally adapted communication and attitudes, multidisciplinary teamwork, and responsiveness to patients’ concerns are key tenets of patient-centredness within the diverse Asia–Pacific environment.²²⁵ Generational, traditional, and cultural perspectives of patients and their families can influence perceptions of CVD risk and perceived benefit of interventions.²²⁶ Prioritising patient-centred concerns, which commonly include medication toxicity, social stigma associated with cardiometabolic diseases, preference for traditional remedies, or unfamiliarity with Western medicine, will be key to delivering culture-specific, patient-centric, and whole-of-family-centred CVD care in the region.²²⁷

Case study

Against a backdrop of a 3000-year history of traditional and alternative healthcare practices such as Ayurveda, Yoga, Siddha, and homoeopathy in South Asia, many of the principles underpinning these therapies have permeated the collective cultural psyche and shaped how many patients understand their disease. Contemporary allopathic understandings of disease arising from pathophysiologic mechanisms may be eschewed in favour of concepts regarding “balance” in the body.²²⁸ Suspicion towards “Western medicine” contributes to non-compliance with guideline-directed medical therapy^227,228 and poor participation in rehabilitation programmes.²²⁹ Discussions around illness, prognosis, and the possibility of impending mortality are sometimes seen as anathema where a death taboo exists in the belief that such discussions might portend that outcome.²³⁰ Patient-centred care in this region involves communicating in the patient's first language and framing the consultation with the patient's cultural references and beliefs to achieve buy-in and participation in treatment.²³¹ Necessary discussions about end-of-life and advanced care plans must be personalised and handled discreetly, and training in cultural competence has been shown to improve physicians' confidence.²³² Family members are often involved in shared decision-making, given the high degree of interpersonal trust²³³ placed on the wider family unit to make treatment decisions, especially among elderly patients who are less educated and financially dependent on their children.²³⁴

Domain 3: Outcomes

Regional disparities in healthcare access and quality, Sociodemographic Index, and health outcomes

Health system performance diverges across the socioeconomic development spectrum, with higher SDI countries demonstrating better healthcare performance than lower SDI counterparts. Health systems that recorded the highest HAQ Index were among countries from the high SDI quintile (e.g. Australia and Japan), followed up high-middle (e.g. China and Brunei), and middle SDI quintiles (e.g. Thailand and Sri Lanka). Countries with the lowest HAQ Index were more likely to be from low-middle and low SDI quintiles. Importantly, countries within the middle SDI quintile demonstrated the most remarkable heterogeneity in health system performance, with the highest HAQ Index observed in Thailand (seventh decile) and the lowest in Fiji (third decile). Even among Asia–Pacific countries with similar SDI or HAQ Index, significant within-group heterogeneity remains. These differences are often rooted in distinct governance structures, health system organisations, geographical challenges, and sociocultural influences. Consequently, a ‘one-size-fits-all’ strategy for regional policy implementation is unlikely to succeed; instead, policymakers must adopt nuanced, country-specific approaches to ensure equitable access to CVD care.^6,235,236 A key observation is that there are significant disparities in health systems, socioeconomic development and health outcomes in the Asia–Pacific, with two-thirds of countries in the region recording poor performances (below the 5th decile of the HAQ Index) in terms of the provision of quality and accessible healthcare, and are within the low to middle quintiles of the socioeconomic spectrum; yet, these countries have borne the vast majority of the CVD burden in the Asia-Pacific²³⁷ (Fig. 5). Regional efforts should focus on enhancing health system capacities and socioeconomic development, especially in low to middle-SDI countries, through multinational, multistakeholder approaches in raising funds for healthcare, pooling resources for health insurance, expanding the healthcare workforce, and investing in medical technology, infrastructure, and pharmaceuticals (Box 3).^6,235,236

Fig. 5.

Distribution of countries in the Asia–Pacific across Healthcare Access and Quality (HAQ) Index and Sociodemographic Index (SDI). The distribution of countries within the Asia–Pacific across the HAQ Index and SDI, stratified across the range of cardiovascular disease disability-adjusted life year (DALY) rate (per 100,000 population). Dotted vertical lines represent the different SDI categories.

Healthcare access and quality, and health outcomes

The considerable heterogeneity in regional patterns of health system performance and cardiovascular outcomes highlights the complexities of aligning health systems to provide access to quality healthcare for all people and achieve optimal CVD outcomes across continuums of care.² From 2000 to 2021, excess CVD-related age-standardised morbidity rates in the Asia–Pacific have been widening in relation to global estimates. Regional efforts to reduce the CVD burden have generated optimism about closing the health gap between the Asia–Pacific and the world, with forecast analysis indicating more rapid regional CVD care advancements than global trajectories.¹ Despite moderate successes in CVD prevention in the Asia–Pacific, our study warns that the vast disparity in access to quality healthcare within the region will remain a key challenge for vulnerable LMICs, which may not keep pace with the rapidly growing CVD burden.^6,238 Based on the HAQ Index, countries in the lower deciles (from the first to the fifth) observed higher CVD-related age-standardised morbidity than Asia–Pacific and global estimates in 2021, with these disparate trends likely to persist into 2050. On the other hand, countries with higher HAQ Index deciles (from the seventh to the tenth decile) have observed lower CVD burden relative to regional and global mean estimates, highlighting the benefits of decades of improved access and quality of healthcare²³⁷(Fig. 6). Prioritising efforts to achieve equitable access to quality healthcare across the region, especially in LMICs, will be one of the key tenets for bridging the CVD gap across the diverse health systems in the Asia–Pacific.

Fig. 6.

Age-standardised DALY rates over time for each Healthcare Access and Quality (HAQ) Index decile. Cardiovascular disease age-standardised disability-adjusted life year (DALY) rates (per 100,000 population) over time for each HAQ Index decile, stratified by global and Asia–Pacific estimates. Solid lines represent the age-standardised DALY rate (per 100,000) from 1995 to 2021, and dashed lines represent the projected age-standardised DALY rate (per 100,000) till 2050.

Health spending indices

The measure of health spending as a share of GDP per capita examines the proportion of the country's economic output allocated to healthcare. However, an increasing share of GDP per capita devoted to healthcare did not translate into lower CVD-related age-standardised morbidity (Supplementary Figures S7 and S8). On the other hand, when the measure of health spending was based on the total health expenditure per capita, a direct measure of the average amount spent on healthcare for each person, there was a trend towards increasing total health expenditure per capita, yielding lower age-standardised morbidity and mortality rates (Supplementary Figure S9). While economic commitment to health spending, measured as the health spending ratio of the country's GDP, is important, its effect on health outcomes may vary depending on the country's actual purchasing power. For example, while Singapore and Bangladesh share a similar economic commitment to health spending (5% of GDP per capita), total health expenditure per capita was USD 4306 and USD 71, respectively, in 2021. In addition, among countries with health spending between 5 and 10% of GDP per capita, those with a higher CVD burden tended to be from low-to-middle SDI quintiles (such as the Solomon Islands, Marshall Islands, and Vanuatu). In comparison, counterparts with lower CVD burden were likely from higher SDI quintiles (such as Singapore, Thailand, and China)²³⁷ (Supplementary Figures S7 and S8). Our results demonstrate substantial variation in CVD-related outcomes across countries with similar levels of health spending (as a share of GDP), driven by each country's socioeconomic development and spending power. As such, the decoupling observed between health care spending (as a share of health spending of the GDP) and health outcomes may not be informative for LMICs given the low baseline health expenditure. Instead, the study suggests a greater focus on increases in total health expenditure per capita, which can, at least in most cases, lead to improvements in CVD outcomes.²³⁹

Health access and quality, and Sociodemographic Index

Despite municipalities increasing health expenditure, empirical evidence on its translation into health inputs and outputs—including health infrastructure, human resources, primary care services, and CVD tertiary care—and health outcomes remains unclear.²³⁹ A key component in the chain linking variation in health expenditure and outcomes is heterogeneity in access to quality healthcare and service utilisation.²³⁹ While higher spending can lead to greater utilisation and investments in CVD care, with substantial returns in later-life survival, higher health expenditure may not efficiently translate into better CVD outcomes if access to health care and service utilisation are not well addressed.²³⁹ For example, in countries with similar total health expenditure per capita (e.g., between 500 and 2500 USD per capita), those with a higher HAQ Index had a lower CVD burden (e.g., Thailand and Sri Lanka) compared to those with a lower HAQ Index (e.g., Niue, Palau, and Fiji) (Fig. 7).²³⁷ On the contrary, based on the country's socioeconomic status alone, high-middle SDI countries (e.g., Niue and Palau) did not report lower CVD burden than middle SDI countries (e.g., Thailand and Sri Lanka) (Supplementary Figure S9). When comparing countries with similar total health expenditure per capita, regional analysis suggests that a country's healthcare performance (measured by HAQ Index) was more closely related to CVD outcomes than its overall socioeconomic status (measured by SDI). It is not surprising that the effectiveness of increasing health expenditure in improving health outcomes, particularly in LMICs, is lower, given that life expectancy is generally lower and unmet socioeconomic challenges are prevalent in these countries.^239,240 While health spending can substantially expand health inputs (e.g. hospitals and human resources for CVD care), it is the increase in access to quality health care services that ultimately leads to improved CVD outcomes.²³⁹ Nevertheless, socioeconomic development remains a significant predictor of the country's healthcare access and quality.⁶ Social and commercial determinants are barriers to healthcare access and quality through inadequate investment in health, ability to pay, and education.^{6,236,241,242} Furthermore, LMICs are likely to allocate a significant proportion of government health funds to other public health crises (such as tuberculosis and malaria), suggesting that CVD investments might not keep pace with the rapidly growing CVD burden.^6,238

Fig. 7.

The correlation between age-standardised morbidity and mortality rates, and total health expenditure per capita, across countries in the Asia–Pacific in 2021. Increasing total health expenditure per capita (Purchasing Power Parity [PPP] adjusted in 2024 US dollar [USD]) correlated with decreasing (A) age-standardised disability-adjusted life year (DALY) rates (per 100,000 population), as well as (B) age-standardised mortality rates (per 100,000 population). Countries across the Asia–Pacific were stratified based on Healthcare Access and Quality (HAQ) Index decile, and population size.

Health spending efficiencies and health outcomes

Higher health spending does not always translate to better CVD outcomes. Inefficiencies and resource misallocation can limit its impact, underscoring the need for integrated financing reforms and system redesign, quality improvement initiatives, and accountability frameworks.^243,244 In terms of health spending efficiency, high- and high-middle SDI countries have demonstrated high health spending per capita with good CVD outcomes (e.g., Australia, Singapore, Japan, South Korea, New Zealand, and Taiwan). In contrast, other high-middle SDI countries had relatively poorer CVD outcomes despite high health spending (e.g., Niue and Palau). On the other hand, across the middle SDI countries, some demonstrated efficient health spending with relatively good CVD outcomes despite lower health spending (e.g., Thailand). Others of similar SDI standing recorded poorer CVD health (e.g., Nauru) (Supplementary Figure S10).²³⁷ Similarly, based on health system performance, countries with higher HAQ Index observed relatively better CVD outcomes with effective health spending (e.g., high spending and good outcomes in Australia and Singapore) and efficient spending (e.g., low spending and good outcomes in Thailand and Sri Lanka). On the contrary, countries with lower HAQ Index observed poorer CVD outcomes (e.g., low spending and poor outcomes in Nauru, Marshall Islands, Vanuatu), while others demonstrated relatively less effective health spending (e.g., high spending and poor outcomes in Niue and Palau) (Fig. 8).²³⁷ Health spending as a share of GDP per capita is shown in Supplementary Figures S11 and S12.

Fig. 8.

Health spending efficiencies and cardiovascular disease burden across the Asia–Pacific in 2021. The total health expenditure per capita (Purchasing Power Parity [PPP] adjusted in 2024 US dollar [USD]) residual Z-scores plotted against the (A) age-standardised disability-adjusted life year (DALY) rates (per 100,000 population), and (B) age-standardised mortality rates (per 100,000 population) residual Z-scores for each country depict the four quadrants of health spending efficiencies and effectiveness—countries with low healthcare spending but high cardiovascular disease (CVD) burden, high healthcare spending and high CVD burden, low healthcare spending and low CVD burden, and high healthcare spending but low CVD burden. Countries were further stratified based on Healthcare Access and Quality (HAQ) Index decile, and population size.

While the updated estimates of health spending, health access and quality, and cardiovascular outcomes provide a contextualised overview of the vast diversity in cardiovascular care delivery within the region, these data may not be fully representative of the dynamic health system landscape within the region. For example, China's coordinated tripartite medical reform has rapidly led to strengthened primary care and public health capacity (focussing on population-wide screening and community-based services), expanding medical insurance and provider-payment reforms (such as the diagnosis-related groups and diagnosis-intervention packet payment models), deepening national volume-based procurement, and insurance price negotiations with dynamically updated formularies. Collectively, these are likely to reshape spending composition, pharmaceutical prices, provider incentives and income structures, and access to cardiovascular care, which may not be possible to fully account for in the present analysis.^245,246

Discussion

Amid advances in personal healthcare access and quality, a more nuanced understanding of subnational inequalities in these areas is crucial. For example, in 2016, China was in the eighth decile of the HAQ Index, but it had provinces spanning from the tenth decile (Beijing) to the fourth (Tibet), with higher healthcare performance in eastern provinces than in western provinces.⁶ In the same year, India was in the third decile of the HAQ Index, with subnational healthcare performances spanning from the sixth decile (Goa and Kerala) to the second (Assam and Uttar Pradesh).⁶ These disparities in personal healthcare access and quality within China and India are likely multifactorial, including significant differences in physical access to health care services, health system infrastructure, medical technologies and innovations, and the provision of effective services to all populations across continuums of care.^6,247,248 Moreover, regional studies have revealed that healthcare inequities might be contributed by the “cream-skimming” effect driven by disparate systemic, structural factors, whereby high-ranking officials have received priority access to high-level health services, thus exacerbating subnational disparities in healthcare access, resource allocation, and cardiovascular outcomes within the general public.²⁴⁹ Moving forward, there is a need to incorporate progress in healthcare access and quality into more comprehensive evaluation tools for health system performance, and expanding subnational CVD burden evaluations to all countries in the region will support this endeavour to quantify health system inequalities across and within countries.

The rural-urban divide particularly in large Asia–Pacific countries such as India and China, can lead to substantial disparities in cardiovascular outcomes. Studies in China and South Asia have reported higher rates of CVD (9.71 vs 6.77 per 1000 person-years in China; 5.41 vs. 4.73 per 1000 person-years in South Asia) and cardiovascular-related deaths (8.09 vs 3.04 per 1000 person-years in China; 10.27 vs. 6.56 per 1000 person-years in South Asia) in rural compared to urban regions, respectively.250, 251, 252 The rural-urban inequity in cardiovascular outcomes is largely contributed by a multitude of factors such as 1) low education impacting survival through wider downstream effects (i.e. occupational-related risk factors, community structure, and reduced access to healthcare services) particularly within poorer and rural communities; 2) poor quality diet with healthy foods being expensive and unaffordable in the majority of the rural population in South Asia²⁵¹ and China²⁵²; and 3) household air pollution identified as one of the largest population-level cardiovascular risk factor in rural populations,²⁵¹ given that over two-thirds of households in rural regions still use solid fuels or kerosene for cooking. Addressing the rural-urban divide will first require better comprehension of context-specific barriers to access to health care and redirecting effective system-level changes at overcoming these entrenched barriers.²⁵¹ Future research should be performed to precisely understand the pathways and mechanisms of the impact of the rural-urban divide across socioeconomic status on cardiovascular outcomes in Asia–Pacific countries.²⁵³

In addition, with the epidemiological transition in most Asia–Pacific countries, the gap in healthcare access and quality will continue to widen. The responsiveness of health systems drives these shortcomings as they evolve to meet their populations' needs, exacerbated by the lack of robust primary health care in LMICs. Prior studies have reported that the HAQ Index increased more in the young population than in the working and post-working populations from 1990 to 2019.⁶ The improved performance in healthcare access and quality in the young population within the region, although far from fully realised, demonstrates moderate successes in the policy prioritisation, investments, and technology innovations focused on this demographic. However, the slower improvements in healthcare access and quality for working and post-working populations highlight an area of concern for the region, especially with CVD care in the older population, requiring more complex strategies in organisational capacity, higher expenditure, and different diagnostics, technology, and treatment.^93,254,255 Health systems in the Asia–Pacific will need to ensure access to quality healthcare for the working-age and older adults, while concurrently improving healthcare access and quality for younger generations.⁶ Health systems must address the population's health needs across the life course, along the continuum of care, that adopts a holistic approach to cardiovascular health rather than focussing on a single risk factor or disease in silos.^59,256,257 As for high-income countries in the region, care integration focuses on managing multiple morbidities among the elderly, a high-cost population.³ The lags in the evolution of healthcare access and quality towards enhancing elder care, however, will have broader socioeconomic implications for the working and post-working age groups, with women and children often bearing the brunt of care-taking duties, as well as consequences for gender equity.²⁵⁸ Furthermore, the shrinking labour force and productivity in the working-age population due to limited access to high-quality health care services will affect the country's ability to address dependency ratios and benefit from the demographic dividend.²⁵⁹ As such, primarily in high-income countries, age-specific indices of health access and quality should be developed to provide a more comprehensive understanding of how healthcare access and quality vary across the lifespan. This would better inform the effectiveness of health systems and the response to the broader demographic transition and the ageing population.²⁶⁰

In this era of social, political, and economic transitions across the Asia–Pacific, effective health spending and the prioritisation of access to quality CVD care will be key tenets for addressing the growing CVD burden in all Asia–Pacific countries. The transition towards mobilising additional domestic resources for health spending and shifting away from high out-of-pocket payments will be essential to keep the region's poorest populations out of catastrophic cardiovascular health impoverishment. Ensuring access to quality healthcare will be critical to achieving universal health coverage and improving CVD outcomes across the region. As the economy in the region continues to grow rapidly, more middle-income countries in the Asia–Pacific will be able to solidify their capacity in domestic spending on cardiovascular health, and will be well-positioned for stability in the future, with the collective vision that more countries can potentially create space for limited development assistance dollars to aid the region's most vulnerable populations.⁴ Given the vast inequalities across Asia–Pacific countries, there is an urgent need for concerted efforts in policy-making and resource allocation towards vulnerable regions at risk of being left behind. While current performance reflects past public health policies, the pace of socioeconomic progress could benefit LMICs if recent gains are reinvested to strengthen and deliver health systems for the next generation.

Conclusion

Despite substantial gains in CVD care in the Asia–Pacific, many LMICs face considerable obstacles in providing personal healthcare access and quality, unless enhanced policy action and investment are aligned to improve access to and quality of CVD health services. The stagnated trends in improving CV health in low-to-middle SDI countries in the region are underscored by complexities in the organisation of primary and secondary cardiovascular services, fragmented care delivery models, disparities in health service financing, and limited quality infrastructure. While public health programmes require further strengthening, the pursuit of universal health care hinges upon a more in-depth focus—and subsequent provision—of quality health care and systems in all populations in the Asia–Pacific. On the other hand, high-income Asia–Pacific countries will face multifaceted and complex challenges with the enlarging cardiometabolic multimorbidity burden in the ageing population, focused on delivering integrated elderly cardiovascular care planning, shifting from inpatient acute care to multidisciplinary care delivered in the community, while lowering overall healthcare costs and improving patient experience and quality of care. With the effective and tailored public health strategies within the region, the Lancet Commission on Tackling CVD in the Asia–Pacific is focused on improving healthcare access and quality in CVD prevention and treatment, across the spectrum of development within the region, reaffirming the foremost commitment in accelerating progress for the world's most populous, yet one of the poorest, region.

Contributors

Authors NWSC, SJN, CSPL, GK, FAC, CKC, CG, YG conceptualised the study.

Authors NWSC, GK, FAC, YC, BC, RG, YG, HRH, SJN, CSPL curated and analysed the study data, and carried out investigation and methodology.

Authors NWSC, GK, FAC, YC, BC, RG, YG, HRH, SJN, CSPL wrote, reviewed and edited the manuscript.

Authors CKK, CG, TM, AJN, GR, AR, AR, NS, MS, KCBT, PT, JT, LLY, KKY conducted investigation, reviewed and edited the manuscript, and supervised the research.

All authors reviewed the final manuscript for publication.

Data sharing statement

All data and codes used are available upon reasonable request to the corresponding authors.

Editor note

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Declaration of interests

N.W.S.C has received research grant support from NUHS Seed Fund (NUHSRO/2022/RO5+6/Seed-Mar/03), National Medical Research Council Research Training Fellowship (MH 095:003/008-303), National University of Singapore Yong Loo Lin School of Medicine's Academic Fellowship Scheme, the NUHS Clinician Scientist Program (NCSP2.0/2024/NUHS/NCWS), CSDU Clinician-Scientist Grant, and the National Medical Research Council Transition Award (TA24jul-0008).

M.S has been supported by research funding from Polybio, Pfizer, and Novartis through Yale University; he has also received lecture honoraria from Boehringer Ingelheim.

K.C.B.T has received honoraria for lectures from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, and Sanofi; and advisory board fees from Daiichi Sankyo, Eli Lilly.

J.T is supported by the National University of Singapore Start-up grant and the CS-IRG from the National Medical Research Council; has received research support from AstraZeneca and consulting or speaker fees from Roche Diagnostics, and owns a patent US-10702247-B2 unrelated to the present work.

S.J.N has received research grant support from AstraZeneca, Amgen, Anthera, Cerenis, Eli Lilly, Esperion, InfraReDx, LipoScience, The Medicines Company, New Amsterdam Pharma, Novartis, Resverlogix, Roche, and Sanofi-Regeneron; and has received consulting fees from Akcea, Amarin, Anthera, AstraZeneca, Boehringer Ingelheim, CSL Behring, Eli Lilly, Esperion, Omthera, Merck, Resverlogix, Sanofi-Regeneron, Takeda, and Vaxxinity.

CSPL has received research grants from the National Medical Research Council of Singapore, Novo Nordisk, and Roche Diagnostic; has received consulting fees from Alnylam Pharma, AnaCardio AB, Applied Therapeutics, AstraZeneca, Bayer, Biopeutics, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Corteria, CPC Clinical Research, Cytokinetics, Eli Lilly, Impulse Dynamics, Intellia Therapeutics, Janssen Research & Development LLC, Medscape/WebMD Global LLC, Merck, Novartis, Novo Nordisk, Pfizer, Quidel Corporation, Radcliffe Group Ltd., Roche and Us2.ai; has patent PCT/SG2016/050217 pending and patent US Patent No. 10,631,828 B1; US 10,702,247 B2; US 11,301,996 B2; US 11,446,009 B2; US 11,931,207 B2; US 12,001,939; US 12,400,762 B2; and is a co-founder and non-executive director of Us2.ai.