89Background: Evidence from nationally representative studies in low-and middle-income 90 countries (LMICs) on where patients are lost in the hypertension care continuum is sparse. This 91 information, however, is essential for the effective design and targeting of health services 92 interventions, and to assess progress in improving hypertension care. This study aimed to 93 determine the cascade of hypertension care in 44 LMICs -and its variation between countries 94 and population groups -by dividing the progression from need to successful treatment into 95 discrete stages and measuring the losses at each stage. 96 Methods:We pooled individual-level population-based data collected between 2005 and 2016 97 from 44 LMICs. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or 98 diastolic BP ≥90 mmHg or reporting use of medication for hypertension. Among those with 99 hypertension, we calculated the proportion who had i) ever had their BP measured, ii) been 100 diagnosed, iii) been treated, and iv) achieved control. We disaggregated the hypertension care 101 cascade by age, sex, education, household wealth quintile, body mass index, smoking status, 102 country, and region. We used linear regression to predict -separately for each cascade step -a 103 country's performance based on gross domestic product (GDP) per capita, allowing us to identify 104 countries whose performance fell outside of the 95% prediction interval. 105 Findings: 1,100,507 participants were included of whom 192,441 (17.5%) had hypertension. 106 73.6% (95% CI, 72.9 -74.3) of those with hypertension ever had their BP measured, 39.2% 107 (95% CI, 38.2 -40.3) were diagnosed, 29.9% (95% CI, 28.6 -31.3) received treatment, and 108 10.3% (95% CI, 9.6 -11.0) achieved control. Countries in Latin America and the Caribbean 109 generally achieved the highest performance, while those in sub-Saharan Africa performed worst. 110 Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on Funding: Harvard McLennan Family Fund 122 Research in context 123

Background The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach. Methods and findings We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), HbA1c ≥ 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given (“treated”), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%–9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%–5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%–78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys. Conclusions The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured.

Background Approximately 80% of the 463 million adults worldwide with diabetes live in low-income and middle-income countries (LMICs). A major obstacle to designing evidence-based policies to improve diabetes outcomes in LMICs is the scarce availability of nationally representative data on the current patterns of treatment coverage. The objectives of this study were to estimate the proportion of adults with diabetes in LMICs who receive coverage of recommended pharmacological and non-pharmacological diabetes treatment; and to describe country-level and individual-level characteristics that are associated with treatment. Methods We did a cross-sectional analysis of pooled, individual data from 55 nationally representative surveys in LMICs. Our primary outcome of self-reported diabetes treatment coverage was based on population-level monitoring indicators recommended in the 2020 WHO Package of Essential Noncommunicable Disease Interventions. Surveys were included if they were done in 2008 or after in an LMIC, as classified by the World Bank in the year the survey was done; were nationally representative; had individual-level data; contained a diabetes biomarker (fasting glucose, random glucose, or glycated haemoglobin); and had data on one or more diabetes treatments. Our sample included non-pregnant individuals with an available diabetes biomarker who were at least 25 years of age. We assessed coverage of three pharmacological and three non-pharmacological treatments among people with diabetes. At the country level, we estimated the proportion of individuals reporting coverage by per-capita gross national income and geographical region. At the individual level, we used logistic regression models to assess coverage along several key individual characteristics including sex, age, body-mass index, wealth quintile, and educational attainment. In the primary analysis, we scaled sample weights such that countries were weighted equally. Findings The final pooled sample from the 55 LMICs included 680 102 total individuals and 37 094 individuals with diabetes. Using equal weights for each country, diabetes prevalence was 9•0% (95% CI 8•7-9•4), with 43•9% (41•9-45•9) reporting a previous diabetes diagnosis. Overall, 4•6% (3•9-5•4) of individuals with diabetes selfreported meeting need for all treatments recommended for them. Coverage of glucose-lowering medication was 50•5% (48•6-52•5); antihypertensive medication was 41•3% (39•3-43•3); cholesterol-lowering medication was 6•3% (5•5-7•2); diet counselling was 32•2% (30•7-33•7); exercise counselling was 28•2% (26•6-29•8); and weight-loss counselling was 31•5% (29•3-33•7). Countries at higher-income levels tended to have greater coverage. Female sex and higher age, body-mass index, educational attainment, and household wealth were also associated with greater coverage. Interpretation Fewer than one in ten people with diabetes in LMICs receive coverage of guideline-based comprehensive diabetes treatment. Scaling up the capacity of health systems to deliver treatment not only to...

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