Cardiometabolic care gap widens after diagnosis, 76-country analysis finds

A widely held assumption in noncommunicable-disease policy is that the poor are undertreated and that closing the treatment gap would deliver the largest health gains. A pooled analysis published in The Lancet Global Health on September 17 complicates both halves of that idea [s1].

Cardiovascular disease is the reason it matters. WHO's noncommunicable-diseases fact sheet records that cardiovascular diseases account for most NCD deaths — at least 19 million a year — and that 82% of premature NCD deaths occur in low- and middle-income countries [s2].

What the study did

Researchers assembled harmonised, nationally representative health-examination surveys from five WHO regions and applied a single care cascade — disease awareness, treatment, and control — uniformly to hypertension, diabetes, and hypercholesterolaemia [s1]. Disease status came from measured biomarkers, self-reported diagnosis, or current medication; control was defined from measured biomarkers [s1].

The pooled dataset drew on 109 surveys conducted in 76 countries between 2002 and 2024 [s1]. Of 478,947 participants with available data, 315,403 (65.9%) were included: a median age of 40 years (IQR 30–52), 185,209 (58.7%) women and 130,194 (41.3%) men [s1]. Within each country, participants were ranked by a household wealth index into quintiles, and inequality was quantified as the difference between the wealthiest quintile and the poorest, together with the slope and relative indices of inequality [s1].

Inequality grows as patients move through care

The central finding is that wealth-related inequalities widened progressively across the care cascade in all regions, and were most pronounced for disease control [s1]. In other words, the gap between rich and poor is narrowest at awareness and widest at the point that actually protects the heart.

Pooled across regions, the slope index of inequality for control was 4.4 percentage points (95% CI 2.4–6.4) for hypertension, 4.8 (0.6–9.0) for diabetes, and 6.5 (3.8–9.2) for hypercholesterolaemia, each favouring the wealthier [s1]. The relative index of inequality sat at 1.1 for all three conditions [s1].

But the regional pictures diverged sharply. In the Region of the Americas, disease control consistently favoured wealthier individuals, with a slope index of 9.2 percentage points for hypertension (95% CI 4.8–13.5; relative index 1.2) [s1]. In the African Region the pattern inverted: coverage was uniformly low, and the largest absolute inequality favoured the poorest — most strikingly for hypercholesterolaemia treatment, where the slope index was −37.6 percentage points (95% CI −49.7 to −25.5; relative index 0.6) [s1]. Where almost no one is treated, the little treatment that exists does not track wealth in the expected direction.

The counterintuitive part

The study then asked where treating the currently untreated would avert the most cardiovascular risk. It estimated 10-year risk with the Globorisk equations and applied trial-derived relative risk reductions to gauge the achievable absolute reduction [s1].

Baseline cardiovascular risk was indeed higher among the poorest than the wealthiest — 13.6% versus 12.2% [s1]. Yet the achievable absolute risk reduction tracked baseline risk rather than the size of the treatment gap. It was greatest in the European Region, at 3.9 percentage points, and lowest in the African Region, at 2.5 [s1]. Across all regions the achievable reduction was larger in men than in women — 4.6 versus 3.5 percentage points in the European Region [s1].

That is the paper's uncomfortable conclusion, stated plainly: the populations with the largest treatment gaps are not necessarily those that could achieve the greatest absolute reduction in cardiovascular risk by treating the untreated [s1].

What follows from it

Two policy implications flow directly. First, where coverage is uniformly low — the African picture — the authors argue that expanding the supply of care matters more than redistributing access to it [s1]. There is little access to redistribute.

Second, because socioeconomic inequalities widen after diagnosis, screening alone is unlikely to reduce disparities unless it is accompanied by sustained access to treatment [s1]. Finding cases is the cheap part; keeping people in effective, controlling care is where the gap opens.

The authors' overall recommendation is bracing for an equity-focused field: policy should prioritise overall population health over maximising equity within the population [s1]. The argument is not that inequality is unimportant, but that a strategy aimed narrowly at equal treatment coverage can leave the largest avertable burden untouched.

Caveats

The analysis is cross-sectional, so it captures the state of care rather than its trajectory in any one person. The surveys span 2002 to 2024 and five regions, and the care cascade, though applied uniformly, rests on self-reported awareness and treatment alongside measured control [s1]. The consortium is registered as NCT07427355, and the analysis was reported with no external funding [s1].

This article is informational and is not medical advice.