Advancing a Global Health Agenda for Cardiovascular Disease

Cardiovascular diseases (CVDs) are among the most urgent global health challenges of the 21st century. Cases have doubled over the past two decades, with CVD now accounting for nearly one-third of global mortality.¹ While high-income countries have seen a steady decline in CVD mortality over the past few decades, mortality rates are on the rise in low- and middle-income countries (LMICs), which now account for 80% of CVD deaths.² This disparity is driven by multiple factors, including health system constraints, such as inadequate access to prevention services and revascularisation therapies, and rising exposure to modifiable risk factors. These include rapid urbanisation, harmful trade and marketing practices, and a growing burden of psychosocial and environmental stressors, such as air pollution, extreme heat and conflict.^3–5

Regional disparities in the CVD burden are particularly pronounced in the Asia-Pacific region, where rapid demographic and epidemiological transitions are straining health systems. Forecasts indicate that between 2025 and 2050, crude CVD mortality in Asia will increase by more than 90%, despite a projected 23% decline in age-standardised rates, underscoring the impact of ageing populations and shifting risk factor profiles.⁶

As healthcare costs outpace gross domestic product growth, CVD prevention has become both a public health necessity and an economic imperative.⁷ Catastrophic out-of-pocket expenditure from CVD-related care disproportionately impacts low-income communities, deepening poverty and widening health inequalities.⁸ Yet non-communicable disease programmes and research remain chronically underfunded relative to their burden of disease. Investment case projections by the WHO estimate that every US$1 invested in proven interventions for CVD, hypertension, diabetes and tobacco control yields a US$7 return.⁹ Despite this, development assistance for non-communicable diseases (NCDs) continues to account for less than 2% of total global health funding.¹⁰

A paradigm shift is urgently needed, away from viewing CVD as a siloed, vertical programme and toward embedding it as a core component of universal health coverage. Comprehensive prevention strategies must address behavioural and metabolic risks in individuals such as hypertension, diabetes, obesity and dyslipidaemia, as well as structural population-level determinants including air pollution, food systems and climate-related stressors.^11,12

Despite global commitments, prevention and control programmes for CVD are faltering across many LMICs. Common barriers include shortages of trained healthcare providers, weak or absent risk factor screening initiatives, affordability constraints due to gaps in insurance coverage and high out-of-pocket medication costs, and procurement and supply chain failures that disrupt continuity of care.¹³ A review of 16 countries in Asia and the Pacific found that while adult hypertension prevalence ranges from 10–40%, control remains poor: 33–52% of cases go undiagnosed, up to 64% are untreated and as many as 80% are uncontrolled.¹⁴ Similar gaps are observed for diabetes and dyslipidaemia, in which fewer than 10% of individuals with diabetes receive comprehensive, guideline-based treatment, and statin coverage remains as low as 6% in many settings.^15–17

Addressing the growing burden of CVD requires a fundamental reori­entation of public health strategies. This review draws inspiration and learning from successful responses to other global health priorities, including communicable disease threats and efforts to reduce preventable maternal and child mortality. By applying these insights, it aims to inform a forward-looking, pragmatic approach to managing the complex and interrelated drivers of CVD worldwide.

Global Health

Historically, global health was synonymous with combating infectious diseases, driven by the expansion of tropical medicine in the 19th century.¹⁸ This period coincided with major advances in understanding the aetiology and transmission of infectious agents, as well as the development of tools for their diagnosis and control. The ability to scale up interventions was facilitated by the creation of institutional and financing mechanisms that harnessed collective global action, most notably the establishment of organisations, such as the World Bank, WHO, UNICEF and other UN and multilateral agencies.

Since then, the scope of global health has broadened considerably.¹⁹ This evolution reflects the emergence of global threats, such as the HIV/AIDS pandemic, the introduction of cost-effective innovations, such as vaccines and antiretroviral therapy, movements to advance primary healthcare and the social determinants of health, and a moral agenda to end preventable maternal and child deaths in the poorest countries, as outlined in the UN’s Millennium Development Goals.^20–22

Progress across these diverse agendas reflects a growing confidence in the power of global collaboration to effectively respond to even the most complex health challenges. The UN’s Sustainable Development Goals (SDGs) reflect this expanded vision, linking health more explicitly to development and environmental sustainability, including the establishment of targets for NCDs.²³ The global commitment to universal health coverage further reinforces the principle that all people should have access to health services, when and where they need them, without undergoing financial hardship. In parallel with these commitments, global health has evolved to become even more interdisciplinary, drawing on insights from across sectors to advance effective health systems and more equitable health outcomes.

Lessons from Global Health to End Preventable Cardiovascular Deaths

The past two decades have witnessed unprecedented achievements in global health. Between 2000 and 2020, child mortality declined by 59% and maternal mortality by 34%.^24,25 New HIV infections were halved, with reductions in deaths from AIDS, tuberculosis (TB) and malaria similarly approaching 50%.^26–28 The expansion of immunisation programmes led to an 85% decline in measles-related mortality, and polio is now poised for eradication.^29,30

In stark contrast, progress in reducing premature CVD mortality (defined as deaths occurring between the ages of 30 and 70 years) has significantly lagged behind the SDG target of a one-third reduction by 2030, using 2015 as the baseline.^1,31 To close this gap, it is crucial to examine which strategies from past global health successes can be adapted to meet the growing burden of CVD. Just as past health threats were met with bold, system-wide interventions, so too must CVD be tackled with the same urgency, scale and strategic clarity.

Figure 1 summarises five implementation lessons drawn from global health to advance CVD control efforts. These lessons are positioned alongside established frameworks for chronic care and the WHO HEARTS technical package for CVD management in primary care.^32,33 Table 1 profiles the distinctions in disease characteristics, time horizons and health system dependencies between HIV, maternal–child health and CVD that are important to consider when applying the lessons outlined below.

Lesson 1: Simplify and Standardise Guidance

Clear, actionable guidelines are an essential starting point for managing chronic diseases and mitigating CVD risk factors. However, in many LMICs clinical protocols remain impractical and overly complex to implement.³⁴

Valuable lessons on simplification and standardisation can be drawn from the global response to HIV and TB. Early HIV treatment protocols initially adopted from high-income countries were found to be poorly suited for low-resource settings. They required specialist oversight, individualised drug regimens and intensive laboratory monitoring, rendering them impractical for widespread use in LMICs.³⁵ Over time, global guidance evolved to favour standardised treatment with fixed-dose combinations and minimal laboratory requirements. These changes enabled task-shifting, lowered costs, and facilitated rapid scale-up of antiretroviral therapy (ART), resulting in millions accessing life-saving treatment.³⁶

A similar trajectory of success has been observed in the prevention of mother-to-child transmission of HIV. The adoption of simplified, lifelong ART for all pregnant women testing HIV positive led to a doubling of treatment uptake and a dramatic reduction in transmission rates, from 30% to below 5%.³⁷ TB control has followed a comparable model. Standardised short-course treatment regimens, coupled with community monitoring, have been the cornerstone of TB programme success for decades, underscoring the value of simplicity and standardisation in achieving impact at scale.³⁸

CVD prevention can benefit from similar principles. Simplified algorithms for managing CVD risk factors have proven both effective and cost-efficient across diverse LMIC contexts.^36,39,40 The WHO HEARTS initiative exemplifies this approach: launched in 32 LMICs, it implemented streamlined hypertension treatment protocols, enrolling more than 12 million patients and achieving a 38% control rate over 5 years.⁴¹ However, such initiatives remain limited in geographic scope and health system integration. Scaling them will require sustained investment, policy alignment and stronger primary care infrastructure to achieve broader impact.

Lesson 2: Service Integration and Decentralisation

Persistent gaps in financing, health workforce capacity and infrastructure continue to limit access to essential services in many low-resource settings. These constraints impede the scale-up and long-term sustainability of high-impact interventions, particularly those addressing chronic conditions, such as CVD, which require continuity of care and sustained patient engagement.

Two proven strategies to overcome these barriers are service integration and decentralisation. Integration involves delivering multiple high-impact interventions at each point of contact in the health system to enhance efficiency and expand reach. Decentralisation entails shifting routine services to the lowest appropriate level of the health system, typically to primary care and community settings, with the aim of bringing care closer to where people live, to improve accessibility.

Numerous examples demonstrate the effectiveness of these approaches. In immunisation, combining multiple vaccines into a single injection and harmonising delivery schedules for different antigens has significantly improved the efficiency, uptake and coverage.⁴² The Integrated Management of Childhood Illness strategy, introduced in the mid-1990s, tackled leading causes of child mortality through simplified, syndromic protocols delivered by frontline and community health workers in low-resource contexts.^43,44 Around the year 2000, more than 10 million children under 5 years of age died each year, largely from preventable causes such as pneumonia, diarrhoea, malaria and measles, with most occurring in LMICs.⁴⁵

Building on this foundation, programmes such as the Integrated Management of Maternal and Newborn Care and Emergency Obstetric and Newborn Care extended this model by integrating an evidence-informed and standardised package of antenatal, intra-partum and post-natal services to reduce maternal and newborn mortality in resource-limited settings.^46–49

Integration and decentralisation were also central to the success of HIV and TB responses. In the early 2000s, HIV prevalence exceeded 30% in some sub-Saharan African countries, with TB incidence among HIV-positive individuals reaching 10% annually. Decentralised rapid HIV testing, performed by nurses at primary and community levels, dramatically expanded access to prevention, care and treatment programmes.⁵⁰ For TB, innovations in molecular testing such as GeneXpert enabled same-day diagnosis and treatment initiation at primary care facilities, reducing patient loss to follow-up.⁵¹ Given high TB–HIV co-infection rates, integrated service delivery at co-located or specialised facilities significantly improved both coverage and outcomes.⁵²

More recently, community health worker models have emerged as effective alternatives for managing CVD risk. In rural Bangladesh, Pakistan and Sri Lanka, home-based screening and counselling linked to community clinics outperformed conventional clinic-based care for hypertension. These models resulted in blood pressure control among 53% of patients, with a two-thirds reduction in CVD deaths among groups receiving the intervention. The package was further demonstrated to be cost-effective, affordable and acceptable to patients.⁵³ Similar results have been observed in Argentina, Colombia, Kenya, Nepal and China.^54–57

Building on these lessons, programmes are increasingly integrating chronic care platforms for both communicable diseases and NCDs. For example, integrated HIV–TB clinics are expanding to include screening and treatment for hypertension and diabetes.^36,58 In recognition of this evidence, the WHO has recommended integrated CVD risk factor management as one of its ‘best buys’ for NCDs.^11,33 This approach incorporates population-level risk identification, simplified treatment algorithms (e.g. fixed-dose combination polypills that combine antihypertensives, statins and aspirin), task shifting to non-physician health workers, and full integration into primary care services.

Lesson 3: Strengthen Advocacy and Community Engagement

Much of the discussion above has focused on the technical and organisational components of CVD risk factor reduction. However, what is often underappreciated are the processes that support implemen­tation, particularly the critical role of advocacy and community engage­ment in advancing adoption and scale.

The global health community first witnessed the transformative power of advocacy during the HIV/AIDS pandemic. Activism by affected communities in the 1980s and 1990s, especially in high-income countries, shifted HIV from a stigmatised illness to a global health and human rights issue. This movement catalysed unprecedented public awareness, civil society mobilisation and international financing, which extended from wealthy countries to regions hardest hit by the epidemic. It also led to the creation of major financing and governance mechanisms including the Global Fund to Fight AIDS, Tuberculosis and Malaria (2002), the US President’s Emergency Plan for AIDS Relief (2003), which has invested over US$100 billion, and the establishment of a dedicated UN agency, UNAIDS.^19,59

Health was further elevated as a development priority under the MDG framework, which was arguably one of the most successful global campaigns in history. The MDGs galvanised political commitment, financing and grass-roots engagement to tackle some of the world’s most pressing health and development challenges.⁵⁹

Community engagement has also proven indispensable to programme success. Peer-led interventions and outreach were foundational to global HIV control.³⁵ For TB control, community-based directly observed therapy has served as a cornerstone, with health workers and volunteers supporting case finding, contact tracing and treatment adherence.⁶⁰ Similarly, community platforms have underpinned progress in maternal and child health.⁴⁵ From Indonesia’s network of nearly 300,000 village-based posyandus to India’s more than 1.3 million anganwadi centres, community volunteers have been crucial to the planning, monitoring and delivery of essential services in resource-limited areas.⁶¹

Advocacy and community engagement for CVD risk remain at an early stage, but the momentum is building. Policy makers and budget holders are coming to recognise the importance of CVD and the high costs of inaction. National campaigns to raise awareness, promote screening and reduce risk factors have been launched in India, Indonesia and across the African continent.^62–64 These efforts are increasingly supported by community-based interventions, with emerging evidence highlighting positive effects on CVD risk reduction. A systematic review across 27 countries demonstrated that enhanced risk factor awareness, physical activity and dietary habits resulted in significant improvements in blood pressure and blood sugar measurements.⁶⁵ In India, community healthcare workers are now engaged in NCD risk assessments and referrals.^44,66 Although challenges persist, early efforts are laying the groundwork for a scalable, community-driven approach to CVD prevention and control.

Lesson 4: Address Social and Commercial Determinants of Health

In 1985, Geoffrey Rose observed stark differences in blood pressure between UK civil servants and Kenyan nomads, attributing this to population-level risk exposures rather than individual pathology.⁶⁷ His insight that small shifts in population risk can prevent more disease than targeting high-risk individuals alone lays an important foundation for a public health approach to CVD.

Addressing the social and commercial determinants of health has been a pivotal global health strategy to respond to population-level risks.⁶⁸ In maternal and child health, investments in girls’ education, women’s empowerment, and financial protection (e.g. conditional cash transfers and free maternity care) have contributed to increased facility-based deliveries and reductions in maternal and neonatal mortality.^69,70 In HIV/AIDS, tackling structural barriers, such as stigma, decriminalisation and gender-based violence, has improved testing uptake, treatment adherence, and has reduced behavioural risks.^71,72 At the same time, regulating commercial influences, such as curbing harmful marketing of infant formula companies and negotiating lower prices for antiretroviral drugs, has been instrumental for both addressing population risks and scaling life-saving interventions.⁷³

CVD shares many of these upstream drivers. Poverty, education, urban planning and the aggressive marketing of tobacco, alcohol and ultra-processed foods all shape CVD risk. Low-income populations, especially in LMICs, face limited access to nutritious food and safe physical activity spaces, contributing to higher rates of hypertension, obesity and related conditions.^74,75 Quantitative data to underpin the effects of these complex social and commercial drivers are emerging. A meta-analysis of 16 longitudinal studies found that individuals with poor social relationships had a 29% higher risk of coronary heart disease and a 32% higher risk of stroke compared with those with stronger social networks.⁷⁶ In Brazil, ultra-processed food consumption was estimated to cause nearly 19,200 premature CVD deaths in 2019, and modelling suggested that a 10% reduction in consumption could prevent about 2,100 deaths annually.⁷⁷ Finally, policy action on tobacco taxation, salt reduction and alcohol control has been associated with population-wide reductions in CVD risk, including smoking prevalence and decreases in average blood pressure and cholesterol levels.⁷⁸

Recent political momentum underscores this point. At the 78th World Health Assembly, Member States adopted a target to halve the health impact of air pollution by 2040.⁷⁹ This commitment reflects a growing recognition of the environmental drivers of CVD and offers new entry points for public health involvement in urban planning, transport and climate resilience efforts.

Lesson 5: Global and National Progress Monitoring

Monitoring progress is essential for raising awareness, fostering accountability, and improving health system performance. Communicating progress in complex systems requires the use of simplified, high-level proxy indicators that are clearly linked to outcomes. Global and national monitoring are essential for aligning resources, identifying delivery bottlenecks, and enabling course correction based on real-time data, particularly for asymptomatic, chronic diseases such as CVD.

In HIV, for example, the 90-90-90 targets are clear signposts for action, defining 90 percentile targets for access to testing, initiating treatment and viral suppression.²⁶ TB programmes have long relied on core indicators such as case detection, treatment initiation, adherence and success rates.⁸⁰ For maternal and child health, scorecards have been widely used to track antenatal care, skilled birth attendance, immunisation and neonatal mortality. The Countdown to 2015 initiative exemplified how simple tools can foster accountability and drive progress towards the MDGs.⁸¹ Similarly, the UN Commission on Life-Saving Commodities developed dashboards to monitor access to and coverage of 13 essential interventions, providing real-time insights into bottlenecks and delivery gaps.⁸²

Striking the right balance between accountability and practicality is essential. Fragmented, overly complex monitoring systems can undermine national ownership and delay decision-making. The SDG monitoring framework (encompassing 17 goals, 169 targets and 230 indicators) has been criticised as overly burdensome, particularly for LMICs, where data capacity and resources may be limited.⁸³

For CVD, the World Heart Federation’s World Heart Observatory now serves as a global platform for CVD data and analytics.⁸⁴ It aims to support evidence-based policymaking, advocacy and tracking of progress toward SDG target 3.4: a one-third reduction in premature NCD mortality by 2030. Linking global platforms like this to national action plans, community campaigns and simplified scorecards will be critical to the advancement of the CVD agenda. Global modelling of the CVD care cascade suggests that achieving the 80-80-80 targets (i.e. 80% of individuals with hypertension screened, 80% of those treated, and 80% achieving blood pressure control) is feasible by 2040. Meeting these targets could avert 110 million–220 million CVD cases and reduce all-cause mortality by 4–7%, with the greatest impact projected in low-income countries.⁸⁵

A Global Health Approach to CVD

The lessons outlined above echo critical success factors from prior global health movements. With CVD now the leading cause of death globally, and progress toward SDG target 3.4 stalled, a bold, systems-oriented public health approach to CVD is urgently needed. What would such a strategy entail?

We are entering a new era of innovation in CVD prevention and care. Integrated, simplified, and community-delivered models (hallmarks of effective global health responses) can now be applied to CVD risk reduction at scale. Fixed-dose single-pill combinations of two or more antihypertensive agents are recommended in international guidelines and offer an efficient, evidence-based tool to optimise blood pressure control.^86,87 Similarly, polypill formulations combining antihypertensives, statins and aspirin have shown substantial benefit in reducing atherosclerotic cardiovascular disease (ASCVD) events and are particularly well-suited for use in underserved populations.^88,89 Long-term studies have demonstrated that combining low-dose antihypertensives with statins can reduce CVD risk by 29% and could be part of an effective primary prevention strategy.⁹⁰ The WHO’s inclusion of ASCVD polypills on its Essential Medicines List underscores their value, and partnerships between governments and manufacturers are beginning to improve access and affordability.⁹¹

Community-based delivery models have proven successful across global health programmes, and their application to CVD is showing promise. Community health workers have demonstrated effectiveness in screening, education, adherence support and, in some studies, in directly administering polypill therapies for ASCVD, resulting in improved clinical outcomes.^92,93 Community health workers serve as a critical bridge to primary healthcare services, particularly in underserved areas. However, their effectiveness is contingent on robust supervision, referral systems and integration with primary care infrastructure.

Innovative mechanisms to decentralise access are also emerging. Smart medication dispensers equipped with internet connectivity and prescription validation are already operational in countries like Singapore for chronic disease management.⁹⁴ Although further research is needed, adapting these technologies for polypill delivery in low-resource settings could provide a scalable solution to expand access.

Emerging technologies in remote monitoring and artificial intelligence (AI) offer game-changing potential. For example, smart wearable devices have the potential to provide continuous blood pressure readings.⁹⁵ If validated, once linked to mobile apps, these tools can deliver real-time feedback, trigger automated referrals, and alert healthcare workers when intervention thresholds are crossed, making real-time, community-level CVD management a tangible reality.

The operational relevance of each lesson varies by setting. For example, community health worker-led service delivery is central to many LMICs, while high-income countries may benefit more from data-driven care coordination or regulation of commercial determinants. Adaptability across contexts is essential for real-world impact.

Importantly, implementing these lessons in combination can generate synergistic gains. A multi-sectoral, population-based urban hypertension programme spanning Brazil, Senegal and Mongolia (incorporating many of the implementation strategies discussed above), has projected substantial health benefits: a 10% reduction in stroke incidence, a 7.8% decrease in coronary heart disease events, and an overall 8% decline in premature mortality over 10 years.⁹⁶ These findings reinforce the potential of coordinated, systems-level interventions to accelerate progress toward SDG target 3.4 and close longstanding equity gaps in CVD health.

Conclusion

This paper calls for a bold reimagining of the global response to CVD: the leading cause of death worldwide. Lessons from past global health successes suggest that simplifying care, integrating services, mobilising communities, addressing structural determinants, and implementing real-time progress monitoring can collectively drive transformative change. Growing recognition of the economic and societal costs of CVD, coupled with a renewed political mandate and recent innovations (from single-pill combination therapies to AI-enabled scorecards) offers a timely opportunity to close the global CVD equity gap. The message is clear: the tools are available; what is needed now is the collective resolve to implement them.