Why integration of circulatory health interventions in primary care is essential?

 

The incidence of circulatory disorders is increasing worldwide, affecting both low- and middle-income countries and some high-income countries. There is evidence of rising incidence and prevalence rates, even among younger individuals, along with an increasing prevalence of risk factors such as high blood pressure, diabetes, and obesity. These indicators suggest that current approaches are not effective in managing and reducing the burden of conditions affecting circulatory health.

In the process of achieving Universal Health Coverage (UHC), countries must determine the essential health services to be provided through health benefit packages (HBPs) that are cost-effective, taking into account criteria such as disease burden, financial risk protection, as well as social and economic impact. Circulatory diseases, as the leading cause of death and disability worldwide, pose significant financial burdens on individuals and households, due to their chronic nature, making financial risk protection a crucial factor in HBP decision-making. Nevertheless, coverage of non-communicable diseases (NCDs) services in UHC packages is still lagging behind compared to other health areas, such as infectious diseases or maternal and child health. UHC is closely tied to the establishment of a strong, high-quality Primary Health Care (PHC) system, as the first point of contact between communities and the health system. Strengthening PHC is crucial for achieving UHC goals, as it improves access to quality and affordable healthcare services, reduces mortality rates, promotes equity, and plays a significant role in preventing deaths from circulatory diseases through better prevention and health promotion, treatment and follow-up. At the global level, the HEARTS Technical Package, WHO Package of Essential Non-communicable Diseases (PEN) interventions for primary health care provide useful guidance on essential health services to be provided at primary care level for the management of circulatory diseases. In addition, Appendix 3 of the WHO Global NCDs Action Plan and Disease Control Priorities 3rd edition (DCP3) offer a comprehensive list of interventions to be implemented at different levels of care, including an analysis of their cost-effectiveness. Drawing on these existing initiatives, the Global Coalition for Circulatory Health (GCCH) recommends decision-makers to prioritize the following interventions in UHC benefit packages at primary health care level: 

Primary prevention interventions: 1. Simple screening for and counselling on risk factors (unhealthy diet, tobacco use, harmful use of alcohol and physical inactivity) 2. Opportunistic screening for hypertension and CVD/stroke, including use of digital tools for risk reduction, regardless of the level of individual circulatory disease risk. 3. Pharmacological treatment of hypertension prescribing one or a combination of the four classes of anti-hypertensive drugs existing, depending on availability at primary care. Polypill is recommended, when available, for individuals at intermediate absolute risk of CVD. 4. Primary prevention of rheumatic fever and rheumatic heart diseases by providing treatment of streptococcal pharyngitis. 5. Glucose screening test for diabetes, including for pregnant women. 6. Metformin initiation for people diagnosed with diabetes, if no contraindications have been identified. 7. Screening for albuminuria for people living with diabetes and hypertension. 8. Management of albuminuric kidney disease with Angiotensin Converting Enzymes inhibitors (ACEi) or Angiotensin Receptor Blockers (ARBs). 

Secondary prevention interventions: 1. Provision of aspirin for suspected cases of myocardial infarction. 2. Management of ischemic heart disease, stroke and peripheral artery disease through provision of antiplatelet, anticoagulant, blood pressure lowering, blood lipid lowering. Nevertheless, despite the availability of evidencebased, cost-effective interventions for circulatory diseases at primary care, particularly in low- and middle-income countries (LMICs) inadequate investment in PHC, heavy reliance on out-of-pocket payments, and insufficient government funding for noncommunicable diseases (NCDs) is undermining efforts to reduce the burden of circulatory conditions