Hypertension in Pakistan: time to take some serious action

Hypertension is counted as the major cause and most important factor in the development of cardiovascular diseases worldwide.1 However, even in the presence of efficacious antihypertensive agents and intensive research data, large numbers of patients in actual clinical practice still suffer with uncontrolled hypertension. Studies indicate that control rates vary according to various countries and geographic regions.2^,3 Even though, the rate of awareness towards hypertension is quite prominent from 62% in Australia to 72% in US, the control rates are quite discouraging as with to 24% and 35% respectively. In the South Asian region, the scenario is more threatening as China reported only 8% control rates and India with 6% in management of hypertension.4 At present, it is estimated that about 1 billion people worldwide have hypertension (>140/90 mmHg), and this number is expected to increase to 1.56 billion by 2025.5

A similar scenario is seen in Pakistan. The National Health Survey of Pakistan estimated that hypertension affects 18% of adults and 33% of adults above 45 years old. In another report, it was shown that 18% of people in Pakistan suffer from hypertension with every third person over the age of 40 becoming increasingly vulnerable to a wide range of diseases. It was also mentioned that only 50% of the people with hypertension were diagnosed and that only half of those diagnosed were ever treated. Thus, only 12.5% of hypertension cases were adequately controlled.6 Some remote areas like Balochistan, there is a paucity of data but the control rate is likely to get even worse.

In Pakistan, health units range from basic health units (BHUs) to tertiary referral centres. The BHUs cover around 10 000 people, whereas the larger rural health centres (RHCs) cover around 30 000 to 450 000 people. Primary health centre (PHC) units comprise both BHUs and RHCs. The Tehsil Headquarters Hospital (THQ) covers the population at sub-district level.7 Utilisation of these units is generally low due to the lack of services and facilities available, uncooperative staff, and inaccessibility. Just 33% of the population has access to health facilities in an area with a 5 km radius8 that becomes worse as many areas of Pakistan are covered with mountains and hills. This place is a huge burden on District Headquarters Hospital (DHH) as a vast number of population have no choice other than to move there for treatment. As a result this increases, specifically, the work load of the health facility team, and in general, total expenditures. Even though the Ministry of Health in Balochistan has re-strategised by appointing more doctors, pharmacists, and supporting staff, and increasing the medical and technical budgets of the said hospitals, there is hardly any change seen regarding awareness, control or management of hypertension in particular.

The issues on hand are underlining the predisposing factors (such as little or no knowledge of hypertension, non-compliance to the treatment regimen, inability of follow-ups, and financial constraints) and the need to find a solution as soon as possible.9 The scenario is quite disturbing and requires an effective, radical, but immediate plan in order to increase the control rate of hypertension in the Pakistani population. The consequences are no doubt alarming and can lead to unnecessary casualties or the development of further cardiac diseases, thus placing an additional burden on the health system, patients, and, as a result, on society itself.

One option is perhaps to initiate an awareness programme for physicians, pharmacists, and patients. Introduction of generic medicines, availability, and promotion are another prominent space available. Increasing financial budgets and facilities could improve the problem but may be impossible in the light of current political and social unrest. It is time that the patient should be extensively involved in developing the concept of ‘this is your health so you must get involved’. This is achievable only if a ‘pharmacist’ status in hospital is accepted as ‘drug counselor’ by the healthcare system. Being the custodian of drugs, pharmacists play a vital role in educating the patients regarding hypertension, drug use, medication adherence, mentioning and reporting adverse drug reactions, and thus reducing the chances of uncontrolled hypertension rates. During the past 4 years, 350 pharmacists have been appointed by the Ministry of Health, Government of Balochistan in various health-providing centres and it is now time to utilise the full potential of these experts. Pharmacists have to come out of the traditional circle of dispensing, drug supply, and record keeping and to move on the areas that are pharmacist owned. The interaction with patients needs improvement, as they must be educated about their condition, the factors affecting their health, and in what matters they can improve. This is only possible if the pharmacist is involved in the process. Even though at present it seems challenging, a little help from the physicians and regulatory bodies can play a vital role in achieving this goal. It is now time to stop promises and to start practices in order to achieve the premium health status that will be beneficial for all.

• © British Journal of General Practice, 2010.