Background Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is
poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the
association with use of these medicines and blood pressure control in countries at varying levels of economic
Methods We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded
from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study.
Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their
combined cost was less than 20% of the households’ capacity to pay. We related information about availability and
affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression
models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income
countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher
availability of medicines than other countries at the same economic level.
Findings The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and
middle-income countries (except for India) than in high-income countries. The proportion of communities with
four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90),
71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13%
in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering
medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of
65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in
communities that had all four drug classes available were more likely to use at least one blood pressure-lowering
medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59–3·12); p<0·0001), combination therapy (1·53, 1·13–2·07;
p=0·054), and have their blood pressure controlled (2·06, 1·69–2·50; p<0·0001) than were those in communities
where blood pressure-lowering medicines were not available. Participants with known hypertension from
households able to afford four blood pressure-lowering drug classes were more likely to use at least one blood
pressure-lowering medicine (adjusted OR 1·42, 95% CI 1·25–1·62; p<0·0001), combination therapy (1·26,
1·08–1·47; p=0·0038), and have their blood pressure controlled (1·13, 1·00–1·28; p=0·0562) than were those
unable to afford the medicines.
Interpretation A large proportion of communities in low-income and middle-income countries do not have access to
more than one blood pressure-lowering medicine and, when available, they are often not affordable. These factors are
associated with poor blood pressure control. Ensuring access to affordable blood pressure-lowering medicines is
essential for control of hypertension in low-income and middle-income countries.