Cardiovascular diseases (CVD) and associated common co-morbidities like diabetes, obesity, chronic kidney disease, and chronic lung disease, etc., account for one-fourth to half of deaths and disabilities across many countries in the Asia-Pacific (APAC) region. There has been an alarming growth in the number of these diseases in the region. Despite CVD being the leading cause of death and disability, there is inadequate awareness of the CVD burden among people and policymakers. There is implicit policy attention amongst member nations as signatories of resolutions taken by the UN General Assembly (UNGA), World Health Assembly (WHA), and World Health regional assemblies. However, there is high variability in national action plans (NAPs) and their implementation to control CVDs.
While it is understandable that health systems are at different stages of maturation, many countries are not doing enough within their capacities to control CVD. Policy actions aimed at strengthening health systems is fundamental to control CVD. Achieving universal health coverage (UHC) to access needed healthcare services (from promotion to palliation) of sufficient quality in a timely fashion and to not face financial hardships in accessing these is of paramount importance in CVD control.
Most countries focus on disease surveillance of communicable diseases only. However, it is clear that surveillance of non-communicable diseases (NCDs) and their upstream social, economic, environmental, and commercial determinants is equally important to monitor the impact of various policy actions on the trajectory of CVD burden. The ongoing digital transformation of the health sector in many countries will enable the instituting of robust NCD surveillance systems.
Many countries in the APAC region adopt risk assessment tools and practice guidelines (both diagnostic and therapeutic) that evolved in Western developed nations. These risk assessment tools and practice guidelines do not account for determinants (health and non-health) unique to the region. Hence, there is a need to validate some of these in a given country’s context and reframe practice guidelines as per risk-benefit and cost-benefit assessments.
Many countries in APAC have shortages of health workers in general and CVD-related health workers in particular. Many health workers migrate to other developed countries further worsening the situation. However, many health systems have evolved innovative ways of working to address the situation. Community health volunteers and workers have emerged as one of the key components of the health workforce in the region. Many of the skills needed to manage patients with CVDs can easily be imparted to non-specialist health workers like primary care physicians and general nurses. Multi-disciplinary teams consisting of a basic doctor, nurse, and counselor can provide superior chronic disease management services for conditions like diabetes, heart failure, chronic kidney and lung disease, etc. In addition, pharmacists and physiotherapists can be utilized in these multi-disciplinary teams. Hence, there is a need to identify these innovative models of CVD care across a given health system (public or private sector) and disseminate the knowledge for adoption across other systems.
CVDs present with time-sensitive medical emergencies like acute heart attack, heart failure, and brain stroke, where instituting appropriate therapies within a given short time window after the onset of the symptoms (6 hours for heart attack and 3 hours for brain stroke) is critical for optimizing outcomes. These emergencies underlie major mortality and morbidity associated with CVDs. Rapid diagnosis of these conditions is now possible with simple biomarkers (Troponins for heart attacks and brain natriuretic peptides – BNPs for heart failure) even in primary healthcare facilities and ambulances. However, acute brain stroke requires imaging modalities like CT scans and MRIs for rapid diagnosis and treatment. There are a few innovative models of emergency CVD care across the region for others to emulate.
Early detection of atherosclerotic vascular diseases (ASCVD) that underlie heart attacks, brain strokes, limb gangrenes, and heart failure is now possible with easy-to-administer tests like coronary calcium score by CT imaging for ASCVD, serum BNP levels for heart failure, and ankle-brachial index for peripheral vascular disease that underlies limb gangrene even before patients develop symptoms of these common conditions that account for nearly 80 to 90% of CVD burden. Many novel therapies have emerged to prevent the progression of these high-risk conditions if detected early.
Diabetes, hypertension, smoking, high cholesterol, obesity, etc., are well-established risk factors for CVDs and their associated co-morbidities. Simple CVD risk assessment tools are available for identifying people who require good control of LDL cholesterol and these risk factors to prevent ASCVD. CKD, chronic inflammatory states, air pollution, etc., also increase the risk of developing CVD and its progression. There are various well-tested cost-effective screening solutions to identify people at risk of CVD for adoption by countries in their national action plans for CVD control.
Despite robust evidence for primary and secondary prevention strategies for CVD control, population-level adherence to these is very low, even in countries that are not resource-constrained. It requires ‘whole of government, whole of society and whole of systems’ approaches to achieving the set goals in CVD control. A cohesive and well-coordinated action amongst various stakeholders is needed. Alliances of these stakeholders are best positioned to orchestrate needed coordination and collaboration. In the triangle model of health governance, governments, people, and the private sector form the three angles of the triangle. Each has rights, roles, and responsibilities towards the shared objective of CVD control. For example, professional associations are best suited for evolved national practice guidelines using rigorous scientific methods; patient organizations are best suited to impart health education to their peers and other people in the communities they belong to; and industry, development partners and philanthropies can provide financial resources to support efforts of governmental and non-governmental agencies.
Many public policies that have a bearing on determinants of CVD are outside of ministries of health. Pro-health taxes on tobacco, and sugarated beverages, pro-health subsidies on healthy foods, CVD health literacy in schools and colleges, air pollution control, creating avenues for physical activity, etc., that have demonstrated impact on CVD control are generally under the control of other ministries. In addition, departments within the health ministry need better coordination. Within the public healthcare provider system, there is a lack of coordination across different levels (primary, secondary, and tertiary) of care. Added to this, some countries have a federal governance structure, where the responsibilities for health are shared between the national and subnational governments. Hence, countries should evolve ‘health in all’ approaches to achieve better CVD control.
As countries in APAC go through the demographic transition with NCDs, that need lifetime healthcare services, becoming the dominant disease burden financing NCD health needs in general and CVD health needs in particular is becoming challenging even for middle- and high-income countries. Various strategies are being tested, especially by large payers (both public and private) to drive value, i.e., high-quality outcomes (both clinical and patient-reported) for the low cost of providing the services. Purchasing models are gradually shifting from fee-per-service models to pay-for-performance systems. Population health management approaches that aim at investments in community-based health promotion, disease prevention, early detection, rehabilitation, and palliation to reduce the need for hospital-based care are proving effective in driving the value of care. Accountable Care Organizations (ACOs) are an example of value-based care being tested in the USA.
The majority of premature deaths in people less than 65 years of age in the region are due to CVDs. In addition, it is observed that people in the APAC region develop CVDs one decade earlier than that observed in the west. These have a tremendous impact on the economies of countries in the region as they impact the productivity of labor force in their prime of life. Hence, investments towards CVD control not only reduce CVD-related health expenses but also improve productivity and thereby general economy. As international development assistance withdraws from most of the APAC region, countries in the region have to depend on the mobilization of domestic finances or helping each other with what one can share with the other. Philanthropy and corporate social responsibility have been witnessing steady growth in the region along with economic growth. These resources can be pooled along with tax money for financing health in general.
In summary, countries in the APAC region have to take more urgent actions to control the burden of CVDs and their associated co-morbidities not only to bend the growth curve of CVD prevalence and incidence, mortality, and morbidity but also to realize the tremendous economic potential of the region. Alliances of like-minded stakeholders can enable needed cohesive and collaborative action learning from each other. Many strategies mentioned above can be easily customized to a given country’s context. There is a need for systems thinking and approach to realize the goals.