Global development has brought a welcome uplift in the quality of life for billions of people. But this transition has also introduced the new risk of cardiovascular disease through changing diets and lifestyles, placing pressures on sometimes-fragile healthcare systems. Here, in an article from our publication Healthy Hearts, Dr Gindo Tampubolon, Professor Delvac Oceandy, and Dr Asri Maharani discuss their work on health screening to identify and manage those at risk of cardiovascular disease, and how lessons from Indonesia can shape global development policy worldwide.

• Three quarters of cardiovascular deaths occur in lower- and middle-income countries.
• Mobile app-supported community screening can identify those most at risk of disease, allowing for health interventions like medication and lifestyle changes.
• Such innovations are a cost-effective way of reducing mortality and disease-burden, and can form the model for global health policy, and UK overseas development strategies.

Gains from social and economic progress over the last century have lifted billions out of extreme poverty, and reduced the scourge of infectious diseases. However, this epidemiologic transition threatens to leave behind people in lower- and middle-income countries (LMICs), with non-infectious and chronic diseases now coming to the fore. Cardiovascular diseases (CVD) are the leading cause of death worldwide according to the World Health Organization, claiming 17.9 million adult lives each year – or one-third of global deaths. But a global figure can reveal as well as hide: three quarters of these cardiovascular deaths occur in LMICs.

The focus of research and policy should be on building and implementing cost-effective health interventions to reduce the burden of CVD in these countries. Such reduction can be achieved by helping adults manage their long-term conditions which already put a strain on the constrained healthcare system.

Sustaining health, reaping wealth with mobile technology

A project led by The University of Manchester, SMARThealth Indonesia, takes this focus by developing and implementing a mobile app-supported system that helps the Indonesian health system identify and better manage people at high risk of CVD. This work showed that 15% of high-risk patients in villages where SMARThealth was used were taking medications to manage their risk factors at follow-up, compared to just 1% receiving usual care, with the greatest difference being the use of blood pressure medication. Blood pressure was also lower in the intervention group at follow-up.

Mobile health innovation such as SMARThealth can help primary care systems identify those most at risk of CVD, and by empowering both patients and community health volunteers to make informed decisions, these innovations lower mortality from CVD. Moreover, health professionals are also helped in sharing the task of managing CVD risks in the population. In our follow up survival study of six years in Malang, the promise of the SMARThealth innovation was demonstrated by a reduced number of cardiovascular deaths in the villages, with participants in the SMARThealth trial showing an 18% lower risk of all-cause mortality.

Such effective care decisions are based on accurate information about risk factors of CVD in the villages. The most important behavioural risk factors of heart disease and stroke are unhealthy diet, physical inactivity, drinking and mostly smoking. Among environmental risk factors, air pollution is an important factor. The effects of behavioural risk factors may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These intermediate risk factors can be measured in primary care posts by health volunteers and immediately indicate an increased risk of heart attack, stroke and heart failure.

Therefore, stopping smoking, reduction of salt in the diet, eating more fruit and vegetables, regular physical activity and avoiding harmful use of alcohol have been shown to reduce the risk of CVD. Interventions such as SMARThealth that create conducive environments for making healthy choices convenient and affordable are crucial for motivating people to adopt and sustain healthy behaviours. Identifying those at highest risk of CVDs, and ensuring they receive appropriate advice and treatment, can prevent premature deaths.

Healthy digital dividends worldwide

Our economic evaluation of the SMARThealth innovation demonstrates its cost-effectiveness; at a typical threshold of income per person the intervention is already 95% cost-effective, with savings per person of around US$4,000 for every year of poor health averted, and $3,600 for every CVD event averted. This resulted in it being adopted by the local government of Malang district for scale up, and it has continued to make a difference. Today more than 900,000 adults from rural Indonesia have participated in the scale up, with nearly one in five found to be at high risk of cardiovascular death in the next ten years. Ensuring that those with high CVD risk get the optimal treatment is critical and can only be achieved effectively with harnessing mobile technology in the hands of health volunteers and health professionals as demonstrated by the SMARThealth technology.

In short, the results suggest that instead of reinventing the wheel, efforts can be directed towards culturally adapting and integrating many of the technological innovations and interventions from other LMICs to strengthen health systems across the global South. In Malaysia, for instance, CVD has been the leading cause of death since the 1980s, accounting for 15% of medically certified deaths in 2019 and surpassing cancer-related deaths. Yet many adults remain unaware of their risk levels. We are engaged in efforts to share our learnings with them.

Policy recommendations

Our evidence shows that this intervention provides a cost-effective model for reducing cardiovascular deaths in LMICs. As such, it should be adopted by the WHO beyond the South-East Asia region where the SMARThealth technology has been curated into a best practice. The Western Pacific, Americas, and African regions all contain high proportions of LMICs, where an increased incidence of CVD would place a heavy burden on developing economies.

The UK’s Foreign, Commonwealth and Development Office (FCDO) should also consider its broader adoption where it can be used to support the Commonwealth countries, the majority of which are LMICs. Health is the second biggest component of the FCDO’s Development Assistance programme, with a budget of more than £640 million. Funding programmes like SMARThealth offer a cost-effective allocation of the population health segment of this budget, helping to meet the UK’s commitments under the UN Sustainable Development Goals, as well as the government’s objective of modernising international development, by strengthening health systems and putting the tools and expertise in the hands of local health leaders.