PUTTING CIRCULATORY DISEASES AT THE HEART OF UNIVERSAL HEALTH COVERAGE

The WSO(World Stroke Organization) managed to completely fail at their job of getting survivors 100% recovered and just put in lazy possible stroke prevention ideas. The 10 million yearly stroke survivors are left to rot because of that failure.

 PUTTING CIRCULATORY DISEASES AT THE HEART
OF UNIVERSAL HEALTH COVERAGE

Circulatory diseases pose significant
financial burdens on individuals and
communities, due to their chronic
nature and the need for frequent
visits to health centres, undermining
social and economic development.
They contribute to poverty due to high costs of
care, particularly in the absence of a national
health insurance scheme or when services for
circulatory diseases need to be paid for out-of-
pocket. Medicines and outpatient care, critical
components of circulatory disease management,
are the main drivers of households’ catastrophic
health expenditures.
As a result, individuals are confronted with the
difficult choice of prioritizing medical treatment
over meeting other critical needs and accessing
essential services, such as food and education.
This should not be the case: efforts should be
made to ensure that access to health services
for circulatory diseases is affordable and does
not impose such burdensome trade-offs on
people’s lives.
Several studies have demonstrated an association between expanding primary care, better population health,
fewer hospital visits, lower health costs and generally increased health equity:
A number of countries across the globe made commitments to progressively achieve Universal Health
Coverage (UHC). To achieve UHC, countries need to decide on essential health services that are
effective, taking into account the national burden of disease, financial protection, and overall impact
on society and the economy.
Providing a well-defined package of essential health services at the primary health care level, either
for free or at a low cost, is essential for achieving UHC. Expanding these services, including for
circulatory diseases, could save millions of lives.
PUTTING CIRCULATORY DISEASES AT THE HEART
OF UNIVERSAL HEALTH COVERAGE
Why?
Benefits of a strong PHC for circulatory health
It is essential to move towards comprehensive models of PHC based on multidisciplinary approaches to health care. In this context, countries
should invest in the health workforce, strengthen education, remove unnecessary barriers to working to full scope of practice and support
the implementation of evidenced based practice. As largely demonstrated, health care providers other than physicians, such as nurses and
pharmacists, can play a critical role in the management of circulatory conditions, including hypertension and diabetes, at primary care level,
through proper training and standardized protocols.
Increased availability
of primary care is
associated with lower
total mortality rates
and lower stroke
mortality.
Absence of primary
care doctors has been
linked with greater
risks of developing
hypertension.
A strong primary
care system is
associated with lower
health care costs, as
primary care doctors
usually order fewer
diagnostic tests and
procedures, compared
to specialists.
In the medium to long
term, investments in
the primary health
care system will
contribute to reducing
supplementary
expenditures for
circulatory diseases.
A strong primary care
system increases
continuity of care,
which leads to
less frequent
hospitalizations and
less need for costly
procedures.

WORLD HEART FEDERATIONTHE ROAD TO UHC: WHY INTEGRATION OF CIRCULATORY HEALTH INTERVENTIONS IN PRIMARY CARE IS ESSENTIAL
Several resources, such as Appendix 3 of the WHO
Global NCD Action Plan, the HEARTS Technical
Package, the WHO Package of Essential NCD
interventions for PHC (PEN) and the Disease
Control Priorities 3rd edition, support countries
in determining what interventions for circulatory
diseases should be included in essential health
service packages at the primary care level.
These key documents include a set of
interventions that are considered cost-effective
for the management of circulatory conditions. In
addition, the Guidelines on the Pharmacological
Treatment of Hypertension in Adults (2021)
provide new recommendations for hypertension
treatment, including the involvement of inter-
professional healthcare teams, as a viable strategy
to provide hypertension care at the PHC level.
Based on the available resources
listed above, the GCCH recommends
countries ensure the following
interventions are included in essential
health benefit packages, as part of
national efforts to achieve UHC:
Primary prevention:
1. Optimising health lifestyle: promoting healthy
diet, physical activity, avoiding harmful levels
of alcohol and tobacco smoking cessation.
2. Opportunistic screening for major circulatory
disease risk factors, including hypertension,
dyslipidaemia and smoking and subsequent
cardiovascular risk assessment, if risk
factors are present, using free apps such as
QRisk2 (or similarly validated digital tools)
in all individuals, regardless of their level of
cardiovascular risk.
3. Glucose screening test for diabetes, including
for all pregnant women.
4. Testing for kidney function and albuminuria
in people with diabetes,hypertension and
cardiovascular disease and women who have
experienced preeclampsia.
5. Pharmacological treatment of hypertension
should be available at primary healthcare
level, with the following drugs (depending
on availability):
a. thiazide and thiazide-like agents;
b. angiotensin converting enzyme inhibitors;
c. angiotensin receptor blockers;
d. calcium channel blockers.
6. Pharmacological treatment of diabetes
mellitus:initiate with metformin if no
contraindications have been identified.
Multitargeted treatment (blood pressure,
lipid, glucose, foot care for people with
diabetes, healthy lifestyle counselling) should
be provided for all people, particularly in
those with an elevated cardiovascular risk.
7. Polypills for individuals at intermediate
absolute risk of cardiovascular disease,
where possible.
8. Treatment of streptococcal pharyngitis with
antibiotics for the prevention of rheumatic
fever and rheumatic heart disease.
9. Pharmacological treatment of albuminuric
kidney disease with renin angiotensin system
blockade and SGLT2 inhibitors.
Secondary prevention:
1. Aspirin should be available for suspected
cases of myocardial infarction.
2. Management of ischemic heart disease, heart
failure, stroke and peripheral artery disease
with antiplatelet, anticoagulant, blood
pressure lowering, diuretics and blood lipid
lowering drugs.
3. Assessment of patients with a history
of cardiovascular complications for
social vulnerability and, if necessary,
inclusion in programs covering cost of
pharmacological treatment.
How?
What?
• Interventions are not implemented due to
lack of awareness, commitment, capacity,
and action among policymakers,as well as
economic and commercial factors.
• Gaps in investments for non-communicable
diseases at national and international levels,
coupled with poor technical and operational
capacity of the healthcare system,
undermine the implementation of
effective policies.
• Inadequate prioritization of funding for
cardiovascular and non-communicable
diseases, which has persisted over time, is
important, particularly in low- and middle-
income countries. This problem is often
exacerbated by the influence of
external donors.
• Shortage of health workers, including
general practitioners and specialists,
pose challenges to dealing with non-
communicable diseases and hinder access to
care, particularly in remote areas.
• Lack of awareness and delayed inclusion of
circulatory diseases in primary care service
packages are further obstacles.
The main roadblocks to implementing
cost-effective interventions:
The solutions:
• Overcoming context-specific
barriers requires collaborative
efforts involving multiple stakeholders from
various sectors, including the business sector,
media, civil society organizations, religious
leaders, and regulatory and financing bodies
as well as implementation research to
identify barriers and test solutions.
• Strengthening advocacy and
communication efforts, including
educating policymakers on the burden
of circulatory diseases through evidence
and surveillance data and savings (lives
and financial), is important.
• Roundtables and multistakeholder
dialogues can be effective in
understanding and addressing
challenges related to the implementation
of cost-effective interventions for
circulatory diseases.

THE ROAD TO UHC: WHY INTEGRATION OF CIRCULATORY HEALTH INTERVENTIONS IN PRIMARY CARE IS ESSENTIAL
To achieve UHC and improve health and development, it is crucial to expand coverage of essential services for circulatory
conditions at the primary health care level, by including existing evidence-based interventions in national health benefit
packages. In addition, it is crucial for governments to prioritize PHC in public health funding and health workforce
allocation to improve access to quality health services for circulatory conditions for all by 2030.
Circulatory diseases: Circulatory diseases are
conditions affecting the heart and blood vessels.
These include, but are not limited to, heart
disease, stroke, diabetes, chronic kidney disease,
heart failure and hypertension. Together, they
cause over 20 million deaths and 374 million
years of life lost every year, affecting young and
old, rich and poor, in rural and urban settings, in
all continents.
Non-communicable diseases (NCDs): NCDs
are conditions are not spread through infection.
These diseases are the leading global cause of
death and pose significant risks to health and
development, especially in low- and middle-
income nations. The most common NCDs
include cardiovascular diseases, diabetes,
cancer and chronic respiratory diseases.
Universal Health Coverage (UHC):
The three dimensions defining UHC are:
1. Population coverage: Everyone who needs
health services should be able to access
them, regardless of their ability to pay for such
services or their geographical location.
2. Service coverage: Availability of a full range
of quality essential health services, from
health promotion, prevention, treatment,
rehabilitation and palliative care should
be guaranteed.
3. Financial protection: When accessing such
health services, individuals and communities
should not suffer financial hardship to pay
for them.
Primary health care (PHC): PHC is a health
system pillar focusing on making sure that
people are as healthy as they can be and that
they have access to the care they need, from
staying healthy and preventing diseases to
getting treatment and support when they are
sick or need help. The goal of PHC is to provide
quality care as close to where people live as
possible. A strong PHC is therefore essential to
make UHC truly universal.
Catastrophic health expenditures (CHE):
Catastrophic health expenditure (CHE) occurs
when a household spends more on out-of-
pocket payments for healthcare than they can
afford based on their income or ability to pay.
Primary prevention: Primary prevention
involves actions taken by the individual
to address unhealthy behaviours, such as
smoking, lack of exercise and unhealthy diet,
that are known to be among the main causes of
circulatory diseases.
Secondary prevention: Secondary prevention
of circulatory diseases involves early diagnosis
and taking steps to prevent an existing condition
from getting worse or occurring again. With early
diagnosis, individuals can receive the necessary
treatments and lifestyle counselling, leading to
an improved quality of life.
Polypill: A polypill can be defined as the
combination of two or more medications in
fixed doses provided in a single pill. Polypills
are generally prescribed for the prevention of
circulatory conditions, by controlling risk factors,
such as hypertension and/or high cholesterol.
KEY RECOMMENDATIONS FOR POLICYMAKERS:
CONCLUSIONS
Take action to expand coverage
of essential health services for
circulatory conditions to all by
2030, with the aim of reducing
catastrophic out-of-pocket
expenditures and increasing
availability of and access to
quality health services in
line with the SGD 3 target.
As the fulcrum of Universal
Health Coverage, primary care
should be made a priority for
public health funding and
health workforce allocation.
Prioritize the list of evidence-
based cost-effective
interventions in the design
of health benefit packages
for primary healthcare at the
national level.
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