Strategies to curb the rising burden of hypertension in sub-Saharan Africa: insights from the WHO global hypertension report 2025

INTRODUCTION Hypertension presents a significant and escalating public health burden in sub-Saharan Africa (SSA), driven by population growth, aging, and rapid urbanization. The overall estimated prevalence in Africa is approximately 30.8% [1], with rates as high as 46% in some SSA adult populations [2]. Key risk factors in the region include unhealthy diets, sedentary lifestyles, increased adiposity (characterized by overweight/obesity), aging, lower educational levels, and psychosocial factors [3]. Urbanization drives lifestyle changes. For diabetic patients, poor treatment adherence and being overweight are critical factors in suboptimal blood pressure control [4]. SSA health systems face substantial challenges with poor detection, treatment, and control rates [3]. A striking 99% of hypertensive individuals in Rwanda lack diagnosis and treatment, highlighting systemic weaknesses and competing health priorities [4]. Globally, hypertension is the leading risk factor for cardiovascular disease (CVD) and a major contributor to mortality and disability. The WHO Global Hypertension Report highlights the global impact of hypertension and the urgency to address it, especially in low- and middle-income countries [5]. Addressing hypertension in SSA requires context-specific strategies, such as increasing public awareness, strengthening healthcare infrastructure, improving screening, task-shifting, and enhancing medication adherence. Community-based care offers a promising approach to decentralize and improve control. STRATEGIES FOR PREVENTION AND CONTROL Community-based interventions The WHO report highlights that globally 1.4 billion people had hypertension in 2024, yet only about one in five have it under control [5]. Given the level of awareness and existing sociocultural barriers to care, empowering communities through targeted health promotion and education is a crucial step in combating hypertension [3]. Community-based interventions, which often use mass media with the likes of local newspapers, is one of the most cost-effective ways to raise awareness and significantly lower blood pressure [6]. Nigeria-based programs like “Know Your Numbers, Control Your Numbers” in Lagos and “Measure Your Blood Pressure Accurately, Control it, Live Longer” in Kano state helped provide screening at 330 sites and engage prominent government figures to raise awareness [7,8]. Furthermore, for these campaigns to be effective, they must be delivered by trusted messengers who can bridge the gap between biomedical information and local beliefs, such as traditional leaders, religious leaders, and traditional health practitioners (THPs) who are custodians of community values and beliefs [9]. Studies show that THP involvement is crucial for population participation and can help overcome structural and sociocultural challenges at the community level [10]. THPs can be engaged as partners to help address misconceptions and build trust in the formal health system, as they are often the first point of reference and provide care for many African communities [9]. By leveraging local influencers, health promotion can become more culturally relevant and effective, directly addressing the significant resistance and fear that contribute to poor health [11]. Strengthening primary healthcare An existing shortage of qualified health professionals, particularly physicians, necessitates a strategic re-engineering of the healthcare delivery model in SSA [12]. Task Shifting, which is defined as the rational redistribution of tasks from physicians to nonphysician healthcare providers (NPHCPs) such as nurses and Community Health Workers (CHWs), has emerged as a sustainable solution [12]. The World Health Organization (WHO) and the Pan-Africa Society of Cardiology (PASCAR) have prioritized task-shifting as a means for improving hypertension control [13]. The WHO agenda stresses that integrating hypertension screening and management into primary healthcare services is crucial for long-term sustainability. For instance, the pilot Healthy Hearts program in the Philippines showed a six-fold increase in hypertension control after implementing standardized treatment protocols, reliable medicine supply, and team-based primary care supported by the WHO HEARTS technical package [5]. Similar programs must be implemented to strengthen primary care systems and improve treatment outcomes across SSA countries. CHWs, who are members of the community with basic training in hypertension management, are pivotal to this model. They serve multiple roles, including providing health education on diet and lifestyle, conducting screenings for hypertension, and supporting medical adherence, providing a vital link to the formal health system and increasing access to services for underserved populations [14]. Case studies demonstrate the success of this approach. While some studies, such as the LARK Hypertension Study in Western Kenya, showed only a modest, nonstatistically significant reduction in systolic blood pressure, they did achieve a significant improvement in patient linkage to care and treatment adherence [14]. Systematic Reviews on CHW-led interventions in Low- and middle-income countries (LMICs) have shown that they have a positive effect on blood pressure reduction and improve management in hypertension care [15]. These interventions are not just about filling gaps; they are fundamentally adapting the healthcare systems to the realities of chronic, lifelong care. By decentralizing care from overburdened clinics and making it a continuous, supportive process, this model addresses the critical issue of adherence, a primary driver of poor outcomes. Innovative approaches The WHO Global Hypertension Report 2025 highlights that digital tools, home monitoring and data-driven feedback can enhance patient engagement and help maintain blood pressure control. Practices adopted by countries like the Philippines, and South Korea show that expanding these interventions can lead to significant improvement in hypertension control [5]. Innovative solutions such as mHealth, which involves the use of mobile communication technologies to deliver healthcare services and wellness support for patients and telemedicine present a promising way to overcome geographical barriers and extend the reach of care to isolated, underserved populations [16]. Telemedicine, which uses telecommunications for remote healthcare services, can improve access, quality, and affordable care [16]. The use of simple, cost-effective technologies like Short Message Services (SMS) reminders has also been shown to increase health knowledge and treatment adherence [17]. Real-world projects illustrate the power of mHealth solutions. For instance, the Community-Based Hypertension Improvement Project (ComHIP) in Ghana, which utilized a web-based lifestyle modification platform that significantly improved blood pressure management, with control rates increasing from 42% to 72% [18]. Additionally the AHOMKA pilot study in Ghana demonstrated that an mHealthcare model led to a significant decrease in mean systolic and diastolic blood pressure among participants [19]. Artificial intelligence (AI) is still in its nascent stages but it still holds significant promise. A 2021 systematic review found no studies using AI for hypertension management in SSA [17]; however more recent evidence is emerging. A longitudinal study from a Ghanaian university demonstrated that machine learning algorithms are a feasible and sustainable tool for the periodic evaluation and early diagnosis of hypertension in a workforce [20]. A systematic review further supports the feasibility of using machine learning (ML) for hypertension risk prediction, specifically how ML models based on routine variables, such as age, BMI, diabetes status, and family history, can reliably predict hypertension [21]. A specific study in Jigawa State, Nigeria, achieved high predictive accuracy (area under curve, AUC = 0.8694) using an Artificial Neural Network [22]. Although methodological rigor often remains nascent, relying on small, single-center datasets, the potential for using ML as a high-throughout screening tool is undeniable [22]. This further supported by adjacent research in the region: a multicenter study in Kenya successfully demonstrated that an AI-enabled ECG algorithm can effectively screen for related cardiovascular diseases, specifically left ventricular systolic dysfunction (LVSD/heart failure), in resources limited settings where gold standard echocardiography is unavailable [23]. Overall, this evidence suggests that AI's most immediate value in sub-Saharan Africa lies in scalable risk triage, using simple, noninvasive data to identify high-risk individuals and optimize scarce healthcare resources. Achieving this will require supportive policies that promote centralized or federated health data systems to improve data quality, validation, and generalizability Policy and environmental measures To complement community and health system level efforts, policy and environmental changes are essential for wide population impact. The South African government's legislative approach to salt reduction stands as a powerful case study for the Africa region [24]. In 2013, South Africa was the first country in the World and the first in Africa to pass and implement comprehensive regulations on sodium content in processed foods, mandating reductions in 13 categories [25]. The results of this policy are compelling. A cohort study among South African adults tracking salt consumption and blood pressure over 7 years found a 10% reduction in sodium consumption. This reduction was associated with a significant decrease in blood pressure levels, with every 1-g reduction in sodium linked to a 1.3 mmHg reduction in blood pressure [25]. If these reductions are maintained, it could lead to lower rates of cardiovascular disease mortality, strokes, and heart failure [25]. Beyond dietary policy, urban planning must be considered as a pivotal public health strategy. Urbanization drives a reduction in physical activity, therefore creating environments that promote active lifestyles is far more important [26], such as designing walkable cities and ensuring access to public spaces for exercise. Ethiopia is one of the countries that has adopted the WHO HEARTS program in partnership with Resolve to Save Lives, achieving significant improvements, including doubling hypertension control rates. The Ethiopian government is further supporting this progress by providing accessible walkways, running paths, and bike lanes to encourage physical activity [5]. The health of a population is not solely a medical concern, but it is shaped and cultivated by the policies and environments in which people live, highlighting the need for intersectoral collaboration [26]. OVERCOMING IMPLEMENTATION BARRIERS In many SSA countries, hypertension prevention and treatment are met by large stigma and sociocultural resistance. Misconceptions that only older adults are at risk, along with cultural preferences for spiritual or traditional remedies, contribute to the growing burden of the disease [27]. Research from Limpopo Province, South Africa, showed that individuals with hypertension reported higher levels of internalized and perceived stigma than those with HIV/AIDS [28]. These findings emphasize the need to address stigma as a key barrier to effective hypertension control. The lack of education in rural communities is another significant barrier in addressing hypertension. A successful study in Ghana's Community-based Health Planning and Services (CHPS) program, offered a promising model, integrating hypertension education into rural healthcare delivery and improving both awareness and early detection in underserved areas [27]. Such initiatives should be promoted and adapted across other regions of SSA. Financing is a critical factor in reducing hypertension, yet it remains largely underexplored in SSA. Although controlling hypertension with medication costs only about five dollars per person, many low-income countries struggle to provide this care, often prioritizing prevention over control [5]. Few studies have examined financial support such as reducing out-of-pocket costs or expanding health insurance coverage could improve hypertension outcomes [29]. In contrast, developing countries like Brazil successfully strengthened hypertension control through government-led financing strategies and dedicated health budgets, ensuring access to medications and regular monitoring [30]. This example shows the need for SSA governments to prioritize sustainable financing as part of comprehensive hypertension management programs. CONCLUSION AND POLICY CALL TO ACTION The burden of hypertension in sub-Saharan Africa presents a multifaceted crisis that demands urgent, comprehensive, and regionally adapted responses. The evidence highlighted in this article shows that the crisis is driven by a complex interplay of rapid urbanization, shifting lifestyles, and genetic predispositions, and is exacerbated by under-resourced health systems, profound socio and cultural barriers. A successful strategy requires a coordinated, multipronged effort that combines policies and community-led interventions. Population-level policies, such as mandatory salt reduction in processed foods that has been successfully implemented in South Africa, offer a powerful blueprint for achieving widespread health improvements. These must be complemented by efforts to strengthen primary healthcare, particularly through task shifting to empower community health workers and nurses, thereby decentralizing care and extending its reach to isolated underserved populations. The strategic use of innovative technologies like mHealth and telemedicine can further enhance this reach, enabling remote monitoring and improving patient engagement and adherence to long-term care. A fundamental shift in mindset is required among policymakers and stakeholders; they must view hypertension not merely as a medical problem, but as a social and economic one, necessitating sustained investment and broad intersectoral collaboration to build resilient, equitable health systems for the 21st century. The WHO 2025 hypertension agenda shows that controlling hypertension is practical and cost-effective. Its core strategies focus on integrating hypertension management into health systems, expanding access to affordable medication and validated monitoring devices, raising public awareness and promoting healthier lifestyles through initiatives supported by the government. Fully implementing the WHO agenda could significantly reduce the burden of hypertension, improve population health and strengthen health systems across Africa. ACKNOWLEDGEMENTS None. Funding: None. Conflicts of interest There are no conflicts of interest.