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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 4, July/August 2015
AFRICA
193
Why is control of hypertension in sub-Saharan Africa poor?
YK Seedat
Abstract
In sub-Saharan Africa (SSA) in 2010, hypertension (defined
as systolic blood pressure
≥
115 mmHg) was the leading cause
of death, increasing 67% since 1990. It was also the sixth
leading cause of disability, contributing more than 11 million
adjusted life years. In SSA, stroke was the main outcome of
uncontrolled hypertension. Poverty is the major underlying
factor for hypertension and cardiovascular disease. This arti-
cle analyses the causes of poor compliance in the treatment
of hypertension in SSA and provides suggestions on the treat-
ment of hypertension in a poverty-stricken continent.
Keywords:
hypertension, control, sub-Saharan Africa
Submitted 23/3/15, accepted 31/7/15
Cardiovasc J Afr
2015;
26
: 193–195
www.cvja.co.zaDOI: 10.5830/CVJA-2015-065
In sub-Saharan Africa (SSA) in 2010, hypertension (defined as
systolic blood pressure
≥
115 mmHg) was the leading cause of
death, increasing 67% since 1990. Hypertension was estimated to
have caused over 500 000 deaths and 10 million years of life lost
in 2010.
1,2
It was also the sixth leading risk for a life of disability,
contributing more than 11 million disability-adjusted life years.
Hypertension is the major cause of 50% of heart disease,
stroke and heart failure. It is involved in 13% of deaths overall
and over 40% of deaths in those with diabetes.
1,2
Hypertension is
a leading risk for foetal and maternal death during pregnancy, as
well as for dementia and renal failure.
1,2
In SSA, stroke, the major
outcome of uncontrolled hypertension, has increased 46% since
1990 to become the fifth leading cause of death.
1,2
In 1983, an age-adjusted prevalence study of the adult
population of Durban showed that hypertension, according to
the World Health Organisation (WHO) criteria, was highest in
urban blacks of the Zulu tribe (25%), intermediate in whites
(17%), lower in ethnic Indians, and lowest in rural blacks
(9%). Our studies showed that 90% of our Zulu patients had
undiagnosed hypertension, and 58% of Indian patients and
77% of white subjects had hypertension that was untreated or
they had discontinued therapy.
3
The first Demographic and
Health Survey in South Africa in 1998 showed high levels of
hypertension with inadequate treatment status.
4
Low compliance is the main reason for poor control of blood
pressure. Compliance has assumed great importance because it
plays a major role in the successful treatment of health problems.
Compliance is defined as the extent to which a person’s behaviour
coincides with medical or health advice. This behaviour includes
taking medication, keeping health-related appointments, and
making lifestyle changes (diet, alcohol consumption, smoking
cessation and physical exercise).
It is difficult to define compliance in terms of appointment
keeping. Compliance is measured by quantitative and qualitative
measurement of medications, pill counting, hospitalisation of
patients, characteristics of medication, and physician–patient
relationship. Physician compliance is assessed by patient
perceptions, socio-demographic characteristics, behaviour
modification, physician instruction, social support, and reduction
in complexity of drugs.
Compliance in SSA is a major problem in the treatment of
hypertension. However, little is known about the pricing of drugs
in SSA. What is known is that the cost is borne by the patient
(out-of-pocket expenditure) and medication is not subsidised by
government or social insurance. Antihypertensive drugs within
the same class and between classes have large differences in price.
Those drugs listed in the WHO International Drug Indicator
Guide were found to be cheaper. Adding advocated drugs onto
countries’ national lists could reduce the price.
The Oxfam report
5
(2007) titled ‘Pharma companies deny
medicine to millions’ states that big pharmaceutical companies
need to change the way they work, so as to reach 83% of the
world’s consumers who don’t have access to medicines. The
report lists the shortcomings of industry, which (1) had failed to
implement a transparent, tiered pricing policy when prices are set
for all essential medicines according to people’s ability to pay; (2)
continues largely not to channel research and development into
diseases that predominantly affect poor people in developing
countries; (3) continues to be inflexible in protecting intellectual
property, including challenging poor countries in court to stop
using legal public health safeguards; and (4) continues to rely
heavily on donations to get affordable medicines to people, even
though this is unsustainable and sometimes counterproductive.
Affordability of drugs is defined as the number of days’
wages required for the lowest-paid individual to purchase a
one-month supply of generic aspirin (100 mg), atenolol (100
mg), angiotensin converting enzyme inhibitor, lisinopril (10 mg)
and simvastatin (20 mg) daily. The affordability of treatment for
the secondary prevention of coronary heart disease would be 1.6
days in Bangladesh, 5.1 days in Brazil, 18.4 days in Malawi, 6.1
days in Nepal, 5.4 days in Pakistan and 1.5 days in Sri Lanka.
6
In order to improve compliance in patients, drugs need to be
made more affordable. Methods to improve affordability are:
increase efficiency and volume of production of drugs, clarify
treatment guidelines so that manufacturers can concentrate on
fewer drugs, negotiate with manufacturers, publicise the lowest
price, and reduce the credible threat of government action.
7
Drugs are also not always equally available in SSA. The
reasons for unavailability of drugs are: bureaucratic factors delay
licensure and discourage manufacturers from introducing drugs
into low-income countries, manufacturers’ prices are important
causes of unaffordability, import tariffs, a lack of comparative
Department of Internal Medicine, University of KwaZulu
Natal, Durban, South Africa
YK Seedat, MD (NU, Irel), FRCP (Lond), FACC,
Seedaty1@ukzn.ac.za