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Medical Writer & Global Health Data Analyst

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High blood pressure was once considered a disease of wealthy nations. Today, most of the 1.4 billion people living with hypertension are in low and middle income countries  and most don’t know they have it. The challenge is structural. So, increasingly, are the solutions.

The burden has shifted to low and middle income countries

For much of the twentieth century, hypertension was associated primarily with wealthy, aging populations. That picture has fundamentally changed.

According to the WHO’s Global Hypertension Report (2025), an estimated 1.4 billion adults aged 30–79 worldwide are living with hypertension  more than double the 650 million recorded in 1990. Two thirds of those adults live in low and middle income countries (LMICs).

This is not simply a story of global population growth. The NCD Risk Factor Collaboration (NCD-RisC), in a pooled analysis of 1,201 studies covering 104 million participants published in The Lancet in 2021, found that the age standardised prevalence of hypertension has remained broadly stable globally over three decades  at around a third of adults. What has changed is where that burden falls. In many high income countries  including Germany, Spain, Canada, and the UK  hypertension rates have declined, driven by improved screening, treatment access, and tobacco control. Across large parts of sub Saharan Africa, South Asia, Southeast Asia, and the Pacific, rates have risen or remained persistently high. (NCD-RisC, The Lancet, 2021)

In other words, hypertension has not simply become more common, it has become more unequally distributed.

What is driving the rise in lower income settings?

Population aging plays an important role. As life expectancy rises in LMICs, more people live long enough to develop chronic cardiovascular conditions. But aging alone cannot explain the scale of the trend.

Rapid urbanization has reshaped diet and physical activity across many lower income settings in ways that significantly raise cardiovascular risk. Diets once centered on minimally processed foods are increasingly replaced by packaged foods high in sodium and saturated fat. Physical activity has declined as economies shift toward less labor intensive work and cities are not always designed for active transport. Tobacco and alcohol use both established risk factors for hypertension  remain widespread in many rapidly urbanizing regions. (Circulation Research, AHA Journals)

The result is a “double burden” of disease: governments still managing infectious illness while simultaneously facing rising rates of hypertension, diabetes, and cardiovascular disease  often without the health system infrastructure built to handle chronic, long term conditions at scale.

Most people with hypertension are undiagnosed, untreated, or inadequately controlled

What makes hypertension a particularly difficult public health problem is that it develops silently. Most people living with high blood pressure have no symptoms until a serious complication  stroke, heart attack, or kidney failure occurs.

The global treatment gap reflects this. According to the WHO’s 2025 Global Hypertension Report:

1. Around 600 million adults with hypertension (44%) are unaware they have the condition.
2. Approximately 630 million (44%) are diagnosed and receiving treatment.
3. Only around 320 million (23%) have their blood pressure adequately controlled.

These numbers reveal an important distinction: being diagnosed does not automatically mean being controlled. Many people who receive a diagnosis either do not access treatment, cannot sustain it, or are not followed up consistently enough to achieve long term blood pressure control.

In many low resource settings, the barriers are structural rather than medical. Primary care systems face staffing shortages, unreliable medication supply chains, and limited capacity for the long-term patient follow-up that chronic disease management requires. Healthcare infrastructure in many LMICs was built to address acute and infectious illness  not to manage conditions that require monitoring and treatment over decades.

Sub-Saharan Africa illustrates the scale of the gap. A review published in Circulation Research (American Heart Association Journals) found that across LMICs overall, only around 1 in 3 people are aware of their hypertension status, and approximately 8% have blood pressure controlled. Importantly, the disparities are significant even within regions: some countries with comparable income levels show very different control rates, suggesting that health system design  not income alone  is a critical determinant.

Some countries are showing that control is achievable

The treatment gap is large, but it is not fixed. The WHO’s Global Hypertension Report (2025) highlights that while 99 countries currently have national hypertension control rates below 20%, a small number of countries have demonstrated that substantially higher rates are achievable through deliberate health system investment.

South Korea is among the most striking examples. Through health reforms that made antihypertensive medicines widely affordable and capped patient co-payments, the country achieved a national hypertension control rate of 59% in 2022,  among the highest recorded globally. (WHO Global Hypertension Report, 2025)

The Philippines has effectively incorporated the WHO HEARTS technical package into community level primary care services nationwide, achieving 65% facility level control in demonstration areas. (WHO Global Hypertension Report, 2025)

Bangladesh has made rapid progress by embedding hypertension treatment into its essential health service package and strengthening community screening and follow up care. Some regional programs reported increases in hypertension control rates from around 15% to 56% between 2019 and 2025. (WHO, 2025)

These results share a common thread: political commitment, integration into universal health coverage frameworks, and sustained investment in primary care infrastructure. They demonstrate that hypertension control is not determined solely by national income. Health system organization, continuity of care, medication access, and screening infrastructure all play a decisive role.

At the program level, WHO’s Global Hearts initiative supports the core components that higher-performing systems tend to share: simplified treatment protocols, stable medication supply chains, team based care, and digital patient tracking. By the end of 2022, Global Hearts programs had been implemented across 32 low and middle income countries. One component  the Simple app, which tracks hypertension patients through primary care  was deployed in more than 11,400 facilities across India, Bangladesh, Ethiopia, and Sri Lanka, managing over 3 million patients. (JACC International, 2023)

Evidence also suggests that detection does not always require physician led care. Studies in Bangladesh, Guatemala, Mexico, and South Africa found that trained community health workers could screen patients for high blood pressure with accuracy rates exceeding 96% compared to clinicians a finding with significant implications for regions where physician access remains severely limited. (Circulation Research, AHA Journals)

The cost of inaction is high and so is the return on investment

Cardiovascular disease is already the leading cause of death globally, and uncontrolled hypertension is one of its most important risk factors. The economic toll is substantial: the WHO’s Global Hypertension Report estimates that cardiovascular diseases will cost LMICs approximately $3.7 trillion between 2011 and 2025, equivalent to roughly 2% of GDP in those countries. (WHO Global Hypertension Report, 2025, via The Lancet)

This makes hypertension control one of the most cost effective interventions available in global health. Most blood pressure medications are inexpensive generic drugs. The challenge is rarely pharmaceutical  it is systemic. The countries achieving the best outcomes are those that have built systems capable of consistently identifying patients, maintaining long term follow up, and ensuring reliable treatment access over time.

The global target is within reach but only with system level change

In 2013, all 194 WHO member states agreed to a target of reducing the prevalence of uncontrolled hypertension by 25% between 2010 and 2025. (WHO Hypertension Fact Sheet, 2024) Current trends suggest most countries will fall short of that goal. But the existence of countries achieving control rates above 50–60% demonstrates that the barrier is not scientific. Effective medications exist and are widely affordable. The barrier is one of health system design, political prioritization, and sustained investment in primary care.

What distinguishes higher performing systems is remarkably consistent across settings: simplified treatment protocols deliverable at the primary care level, reliable medication supply, longitudinal patient tracking, and community health workers who extend the reach of diagnosis beyond clinic walls.

The WHO estimates that if countries scale up hypertension treatment coverage, 76 million deaths could be averted between 2023 and 2050. (WHO Global Hypertension Report, 2023) The rise of hypertension in low income countries is not an inevitable consequence of development. It is a solvable public health problem  and a growing number of countries are proving it.

Data sources

1. World Health Organization. Hypertension Fact Sheet (2024).
   https://www.who.int/news-room/fact-sheets/detail/hypertension
2. World Health Organization. Global Report on Hypertension (2025).
   https://www.who.int/news/item/23-09-2025-uncontrolled-high-blood-pressure-puts-over-a-billion-people-at-risk
3. WHO Global Report on Hypertension 2025 — published commentary in The Lancet, November 2025.
   https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)02208-1/fulltext
4. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1,201 population-representative studies with 104 million participants. The Lancet, 2021.
   https://doi.org/10.1016/S0140-6736(21)01330-1
5. Circulation Research. Hypertension in Low- and Middle-Income Countries. American Heart Association Journals.
   https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.120.318729
6. JACC International. Implementation of Global Hearts Hypertension Control Programs in 32 Low- and Middle-Income Countries (2023).
   https://www.sciencedirect.com/science/article/pii/S0735109723066330
7. Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Study.
   https://www.healthdata.org