Decomposition of socioeconomic inequalities of hypertension care utilization: Bangladesh experience – BMC Health Services Research

Global Burden of Hypertension and its Link to Sustainable Development Goals

Hypertension as a Major Public Health Challenge

Hypertension, or high blood pressure, is a primary risk factor for non-communicable diseases (NCDs) globally. While classified as a medical condition rather than a standalone disease, its uncontrolled state leads to severe health complications, including heart disease, stroke, and kidney damage. The management of hypertension is critical to public health and aligns directly with Sustainable Development Goal 3 (Good Health and Well-being). Approximately one-third of the world’s adult population is affected by hypertension, which contributes to an estimated 7.6 million premature deaths annually. This significant mortality rate underscores the urgency of addressing NCDs to meet SDG Target 3.4, which aims to reduce premature mortality from such diseases by one-third by 2030.

Key Risk Factors and Demographics

The prevalence of hypertension is not uniform, with significant variations based on multiple factors. Comprehensive approaches are required for its global prevention and management. Key risk factors include:

• Age, with a growing prevalence observed among young adults.
• Sex, with a slightly higher incidence in males (10.6%) compared to females (9.2%).
• Ethnicity.
• Lifestyle behaviors.
• Higher body mass index (BMI), indicating overweight or obesity.
• Socioeconomic status.

Socioeconomic Disparities in Hypertension Management: A Barrier to SDG 10

The Influence of Socioeconomic Status on Health Outcomes

Socioeconomic status is a fundamental determinant of hypertension prevalence and management, creating significant health inequities that conflict with the principles of Sustainable Development Goal 10 (Reduced Inequalities). Research consistently demonstrates that individuals with low socioeconomic status, particularly in low- and middle-income countries (LMICs), experience a higher prevalence of hypertension and suboptimal treatment outcomes. Studies in Kenya, China, South Africa, and Bangladesh have all documented pro-rich inequalities in the screening, treatment, and utilization of healthcare services for hypertension. Factors such as income, wealth, and education level are significant predictors of these treatment inequalities, highlighting avoidable and unjust health disparities.

Barriers to Equitable Healthcare Access

Achieving SDG Target 3.8, Universal Health Coverage (UHC), is essential for mitigating health inequities. UHC ensures that all individuals have access to essential healthcare services without suffering financial hardship. However, numerous barriers prevent equitable access to hypertension treatment, disproportionately affecting disadvantaged populations. These barriers include:

• Financial Constraints: Inability to afford essential medications, diagnostic tests, and follow-up appointments.
• Structural Barriers: Limited availability of healthcare providers, inadequate infrastructure, and long wait times, especially in rural and underserved areas.
• Geographic Disparities: An urban-rural divide in healthcare infrastructure and workforce distribution limits access for remote populations.
• Insurance Gaps: Lack of comprehensive health insurance coverage exacerbates financial burdens.

Case Study: Hypertension Inequalities in Bangladesh and the Imperative for SDG-Aligned Action

Evidence of Growing Disparities

Bangladesh provides a critical case study on the rising trend of socioeconomic inequality in hypertension prevalence and healthcare access. Multiple studies highlight the urgent need for targeted interventions to address these disparities and align with the SDGs.

1. Biswas et al. (2016) revealed significant socioeconomic disparities, particularly in urban areas where a higher prevalence was noted among wealthier individuals.
2. Ali et al. (2019) reported a high prevalence of hypertension (29.7%) and identified major socioeconomic gaps in access to healthcare services.
3. Nujhat et al. (2020) found significant gaps in knowledge and practice regarding NCD prevention among rural populations, despite high awareness levels.
4. Chowdhury et al. (2021) documented a marked increase in hypertension prevalence over time, strongly associated with risk factors like obesity, age, and wealth index.
5. Ahmed et al. (2019) discovered a significant prevalence of undiagnosed hypertension among poorer and less-educated groups, emphasizing the need for enhanced screening.

Factors Driving Inequality in Bangladesh

The complex interplay of socioeconomic factors exacerbates health inequities in Bangladesh. Disadvantaged populations face multiple, compounding barriers to effective hypertension management. Key drivers of this inequality include:

• Wealth index and income levels.
• Educational attainment.
• Geographic location, with rural communities facing a disproportionate burden.
• Employment status, which can affect access to health insurance.
• Inadequate health literacy.

Policy Implications for Achieving Universal Health Coverage (SDG 3.8)

Addressing Structural and Non-Need Factors

The persistence of inequalities in hypertension treatment reflects the “inverse care law,” where populations with the greatest healthcare needs receive the least care. This phenomenon directly undermines the goals of the 2030 Agenda for Sustainable Development. Non-need factors, such as wealth, area of residence, and employment status, create unjust financial and structural barriers that prevent equitable access to care. Addressing these systemic issues is paramount to achieving health equity for all, as envisioned in SDG 3 and SDG 10.

Recommendations for Equitable Hypertension Management

This report’s findings underscore the critical need to address socioeconomic inequalities in hypertension care in Bangladesh and other LMICs. To promote equitable healthcare delivery and advance toward Universal Health Coverage (SDG 3.8), targeted interventions and policy strategies are essential.

• Develop and implement targeted interventions focused on disadvantaged and vulnerable populations.
• Enhance screening and diagnostic services, particularly in rural and low-income communities, to ensure early detection and management.
• Launch comprehensive health education and promotion campaigns to improve health literacy and awareness of NCD prevention.
• Strengthen healthcare infrastructure and workforce distribution to reduce geographic disparities.
• Formulate policies that reduce financial barriers to care and ensure that progress toward UHC is equitable and inclusive.

1. Which SDGs are addressed or connected to the issues highlighted in the article?

SDG 3: Good Health and Well-being

• The article directly addresses SDG 3 by focusing on hypertension, a major global health issue and a significant risk factor for non-communicable diseases (NCDs). It highlights the high prevalence of hypertension, stating that “approximately one-third of the adult population worldwide grapple with hypertension,” and its severe impact on mortality, contributing to “an estimated 7.6 million premature deaths each year.” The discussion revolves around the prevention, diagnosis, and management of this condition, which are central to ensuring healthy lives and promoting well-being.
• The article explicitly mentions the need for Universal Health Coverage (UHC), a key component of SDG 3. It states, “Goal 3.8 of SDGs specifically underscores the critical importance of achieving Universal Health Coverage (UHC), which entails ensuring that everyone has access to essential healthcare services without experiencing financial hardship.”

SDG 10: Reduced Inequalities

• This goal is a central theme of the article, which extensively analyzes how socioeconomic status impacts hypertension prevalence and access to care. The text explicitly states that “The 2030 Agenda for Sustainable Development…underscores the imperative of addressing health inequity as a core component of global development efforts. Objective 10…epitomize this commitment.”
• The analysis details disparities based on income, wealth, education, and geographic location. For example, it notes that “individuals from lower-income households disproportionately face uncontrolled hypertension and significant barriers to healthcare access” and points to “geographic disparities, with rural communities bearing a disproportionate burden of inequitable access to healthcare resources.” This focus on reducing health inequities directly aligns with SDG 10.

2. What specific targets under those SDGs can be identified based on the article’s content?

Targets under SDG 3: Good Health and Well-being

• Target 3.4: By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
  • The article connects directly to this target by identifying hypertension as a “significant risk factor for non-communicable diseases (NCDs) worldwide” and a contributor to “7.6 million premature deaths each year.” The entire discussion on the need for better prevention, screening, and treatment of hypertension is aimed at reducing the mortality and burden of NCDs like heart disease, stroke, and kidney damage.
• Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
  • This target is explicitly mentioned and discussed. The article highlights significant barriers to achieving UHC, such as “financial constraints,” “income-based barriers to treatment,” and “gaps in health insurance coverage.” It emphasizes that socioeconomic factors “heavily influence access to healthcare,” preventing individuals from affording “essential medications, diagnostic tests, and follow-ups necessary for effective hypertension management,” which are all core components of UHC.

Targets under SDG 10: Reduced Inequalities

• Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.
  • The article’s core argument is about the exclusion of certain groups from adequate healthcare based on their socioeconomic status. It details how “low socioeconomic status” is associated with a “heightened prevalence of hypertension, alongside suboptimal treatment outcomes.” The text describes “pro-rich inequalities in the utilization of treatment services” and how “disadvantaged populations face multiple barriers to healthcare access.” Addressing these health inequities is a fundamental aspect of promoting inclusion as outlined in Target 10.2.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Indicators for SDG 3 Targets

• For Target 3.4 (Reduce NCD mortality):
  • Mortality rate from NCDs: While not stated as an official indicator, the article’s reference to “7.6 million premature deaths each year” due to hypertension-related complications directly implies that mortality rate is a key measure of the problem.
  • Prevalence of hypertension: The article provides several statistics on the prevalence of hypertension (e.g., “one-third of the adult population worldwide,” “significant prevalence of hypertension (29.7%)” in a Bangladesh study). This prevalence rate serves as a direct indicator of the risk factor for NCDs within a population.
• For Target 3.8 (Achieve UHC):
  • Coverage of essential health services: The article implies this indicator by discussing access to “screening and treatment of hypertension,” “essential medications, diagnostic tests, and follow-ups.” The disparities in the “utilization of treatment services” between different socioeconomic groups are a measure of unequal service coverage.
  • Financial hardship due to health spending: This is implied through repeated mentions of “financial constraints,” “income-based barriers,” and the inability of individuals to “afford…essential medications.” The article’s emphasis on achieving UHC “without experiencing financial hardship” points directly to this indicator.

Indicators for SDG 10 Targets

• For Target 10.2 (Promote inclusion):
  • Disparities in health service utilization by socioeconomic status: The article provides evidence of this, such as “pro-rich inequalities in the utilization of treatment services for hypertension” and the fact that “poorer and less-educated groups” have higher rates of “undiagnosed hypertension.” Measuring the gap in treatment and screening rates between the richest and poorest quintiles would be a direct indicator.
  • Disparities in health outcomes by geographic location: The article highlights the “urban-rural divide” and “geographic disparities” in healthcare access. Comparing hypertension prevalence, diagnosis, and control rates between urban and rural populations serves as an indicator of geographic inequality.

4. Table of SDGs, Targets, and Indicators

Source: bmchealthservres.biomedcentral.com