Getting on top of rural Asia’s blood pressure

A blood pressure management program for rural communities is cost-effective and could be scaled up in low- and middle-income countries.

SINGAPORE, 29 March 2021 –A study conducted by Duke-NUS Medical School researchers and colleagues shows that a hypertension prevention and management trial could be cost-effectively scaled up for rural communities in low- and middle-income countries. The findings were published in The Lancet Global Health.

The study analysed the budget impact and cost-effectiveness of the Control of Blood Pressure and Risk Attenuation – Bangladesh, Pakistan, Sri Lanka (COBRA-BPS) trial, which was implemented between 2016 and 2019 in 30 rural communities. Health workers who normally conduct maternal and childcare visits were tapped to provide door-to-door blood pressure monitoring and lifestyle coaching. People needing professional care were referred to a general practitioner. Travel and additional medication cost subsidies were provided to people with low incomes and poorly controlled hypertension.

In Bangladesh the trial was implemented by icddr,b in Munshiganj and Tangail districts among 895 hypertensive individuals  in close collaborations with the NCD Control Programme, DGHS, MoHFW. In the COBRA intervention areas six Health Assistants (HAs) measured blood pressure of 447 study patients at homes using a digital blood pressure machine and provided education for promotion of lifestyle. The HAs referred patients with uncontrolled blood pressure to selected sub district hospital where doctors treated those patients following a treatment protocol and mobilized supplies of anti-hypertensive drugs for the patients.

“Cost-effectiveness studies are important for understanding the value-for-money spent on an intervention, while budget impact analyses indicate its affordability,” said Professor Tazeen Jafar, from Duke-NUS’ Health Services and Systems Research (HSSR) Programme, who spearheaded the study in all three countries. “These indicators are important for health planners when they have to choose from a variety of interventions for a number of conditions.”

Prof Jafar and her team calculated the trial’s total costs over each of the three years. Based on this, they calculated how much the trial cost per participant treated and per each member of each country’s general population (per-capita). Finally, they calculated how much it would cost to scale up the program country-wide, and how much would be saved by catching and managing blood pressure early on.

“Studies have shown that reducing BP also reduces the risk of developing coronary heart disease, stroke and cardiovascular diseases (CVD), thus offering the potential for low-cost interventions targeting BP and other CVD risk factors to be both cost-effective and scalable,” explained Professor Eric Finkelstein, also from Duke-NUS’ HSSR Programme, and a co-senior author of the study.

The team found the per-participant and per-capita costs of the trial’s first year were US$10.65/$0.63 for Bangladesh, $10.25/$0.29 for Pakistan, and $6.42/$1.03 for Sri Lanka. The costs were less for the next two years in Bangladesh and Pakistan but increased slightly in Sri Lanka.

Due to the relatively low costs of the trial, the scientists estimate that scaling it up to country level would cost each government less than $10.70 per participant treated in the first year. Costs in subsequent years would decrease as only refresher trainings will be required.

“The government of Bangladesh is committed to expand health services for Non communicable diseases countrywide. I am very pleased to learn that Non Communicable Disease Control Program of DGHS support to icddr,b research has proven COBRA- BPS program would be effective for hypertension control in the rural communities.” said Professor Dr Robed Amin, Line Director, NCDC, at the Directorate General of Health Services, Ministry of Health and family Welfare, Bangladesh.

“I believe scaling up this program at the national level would help doctors averting complications due to Hypertension and also cardiovascular complication due to COVID-19 during the pandemic” said the Line Director of the Non Communicable Disease Control Porgram, at the Directorate General of Health Services, Ministry of Health and family Welfare, Bangladesh” he added.

“Uncontrolled blood pressure is a major risk of heart attack, stroke and kidney failure in Bangladesh, and treating such chronic conditions is expensive. COBRA- BPS intervention is a clear solution for controlling blood pressure at low cost that can be easily scaled up in Bangladesh” said Dr Aliya Naheed, who heads the Initiative for Noncommunicable Disease, Health Systems and Population Studies Division at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and the principle investigator of the COBRA-BPS in Bangladesh

The team is currently discussing how to facilitate scaling up the program in Bangladesh, Pakistan and Sri Lanka with authorities in provincial health departments.

The researchers anticipate that the results can also guide trials in other South Asian countries and are looking forward to expand the program throughout the region.


Reference: Finkelstein, E.A., Krishnan, A., Naheed, A., Jehan, I., de Silva, H.A., et al.

Budget impact and cost-effectiveness analyses of the COBRA-BPS multicomponent hypertension management programme in rural communities in Bangladesh, Pakistan, and Sri Lanka. The Lancet Global Health 2021, ISSN 2214-109X,




About Duke-NUS Medical School

Duke-NUS is Singapore’s flagship graduate entry medical school, established in 2005 with a strategic, government-led partnership between two world-class institutions: Duke University School of Medicine and the National University of Singapore (NUS). Through an innovative curriculum, students at Duke-NUS are nurtured to become multi-faceted ‘Clinicians Plus’ poised to steer the healthcare and biomedical ecosystem in Singapore and beyond. A leader in ground-breaking research and translational innovation, Duke-NUS has gained international renown through its five signature research programmes and nine centres. The enduring impact of its discoveries is amplified by its successful Academic Medicine partnership with Singapore Health Services (SingHealth), Singapore’s largest healthcare group. This strategic alliance has spawned 15 Academic Clinical Programmes, which harness multi-disciplinary research and education to transform medicine and improve lives. 

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About icddr,b:

icddr,b formerly known as International Centre for Diarrhoeal Disease Research, Bangladesh is an international public health research institution based in Bangladesh. Established in 1960, icddr,b has been at the forefront of discovering low cost solutions to key health challenges facing people living in poverty and provides robust evidence of their effectiveness at a large scale. Dedicated to saving lives through research and treatment, icddr,b addresses some of the most critical health concerns facing the world today.

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