Implementing Single-Pill Combination Therapy for Hypertension: A Scoping Review of Key Health System Requirements in 30 Low- and Middle-Income Countries.

Eleanor Bruyn,Ruth Webster,Long Nguyen,Aletta E Schutte,Adrianna Murphy,Pablo Perel

doi:10.5334/gh.1087

Abstract

Objective:The World Health Organization (WHO) included single-pill combination (SPC) antihypertensive medications on their 2019 essential medicines list (EML) to encourage uptake and improved hypertension control. We documented key national-level facilitators (SPCs on national EMLs, recommendation for SPCs in national hypertension guidelines and availability of SPCs on the market) supporting uptake of SPCs in the 30 most populous low- and middle-income countries (LMICs).Methods:A hierarchical information gathering strategy was used including literature and web searches, the use of organisational databases and personal communications with colleagues to obtain information on (1) whether SPC antihypertensives are on national EMLs, (2) whether SPC antihypertensives are recommended in national hypertension guidelines and (3) whether SPCs are available on the market.Results:Eleven of 30 LMICs had all facilitators in place being Egypt, Kenya, Nigeria, Sudan, China, the Philippines, Thailand, Iran, Argentina, Colombia and Mexico. Twenty-six countries had national hypertension guidelines (or similar) in place with SPCs being recommended in 18 of these. Apart from Afghanistan, SPCs were available on the market in all countries. The facilitator least present was the inclusion of SPC antihypertensives on national EMLs at 12 of 29 (Turkey does not have an EML).Conclusion:This study demonstrated that many LMICs have made significant progress in their uptake of SPC antihypertensives and several had included SPCs on their EMLs and guidelines prior to their inclusion on the WHO EML. Despite this progress, the uptake of SPC antihypertensives in LMICs could be improved including through their further inclusion on EMLs.

Highlights

Combination therapy is associated with lower healthcare resource use, which is important for low- and middle-income countries (LMICs) [12]
We considered Bigdeli et al.’s comprehensive framework on access to medicines which details multiple barriers which medications must traverse through the health system before reaching the patient [15], to identify key macro level facilitators including listing of single-pill combination (SPC) on national essential medicines list (EML), recommendations for use of SPCs in national treatment guidelines, and availability of SPCs on the market in each country
Five countries were classified by the World Bank as low-income (LIC), 13 countries were lower-middle-income (LMIC) and 12 countries were upper-middle-income (UMIC) [16]

Summary

Introduction

The majority of patients with hypertension require a combination of 2–3 blood pressure-lowering medications to achieve control [7,8,9], most patients in LMICs still receive monotherapy [10]. First-line treatment with combination therapy has been associated with a significant (34%) risk reduction of cardiovascular events or all-cause death, when compared to those who received delayed combination treatment initiation due to initial monotherapy treatment [11]. This was primarily due to the more rapid and effective BP control [11]. Combination therapy is associated with lower healthcare resource use, which is important for LMICs [12]

Methods

Results

Discussion

Conclusion