Gautam Satheesh, 2024 Emerging Leader
Cardiovascular disease is still the world’s largest killer, with hypertension as its silent, relentless accomplice. Hypertension alone drives over half of its deaths, accounting for one in five of all deaths—more than all infectious diseases combined. Its other steadfast accomplices include diabetes and obesity, which causes 11% and 10% of all cardiovascular deaths respectively.
What do these diseases—jointly causing over 16 million deaths a year—have in common? Once a problem of the high-income countries, low- and middle-income countries (LMICs) now disproportionately bear the lion’s share of their burden and mortality. Incidentally, treatment gaps are also the widest in LMICs, where resource-limited health systems grapple to provide lifesaving medicines.
This is indeed the raison d’etre of the Essential Medicine List (EML): to help countries prioritize their limited resources on the medicines that save the most lives.
The World Health Organization (WHO) recently released its 24th Model EML, with two inclusions that could transform the fight against cardiovascular diseases: triple drug single-pill combinations (SPCs) for hypertension and GLP-1 receptor agonists for obesity and diabetes.
Most people with hypertension eventually need two or more medicines. SPCs confer benefits at all healthcare levels. For patients, a single daily pill can mean the difference between sticking with treatment and silently dropping off. For providers, SPCs convert complex guidelines into easy-to-follow protocols. For health systems, a single pill instead of three can simplify supply chains and lower costs. WHO has endorsed similar combination therapies in the past: two-drug SPCs in 2019 and cardiovascular polypills in 2023. These listings align with the World Heart Federation’s longstanding efforts in scaling SPCs as a central strategy towards achieving the Sustainable Development Goal 3.4: cutting premature deaths from non-communicable diseases by a third by 2030.
Another key strategy towards achieving these goals, as proposed by the WHF, WHO and various other global health efforts, is tackling obesity. World Heart Report (2025) highlights obesity as a direct hindrance towards four distinct Sustainable Development Goals, with pervasive economic and health impacts. The EML listing of GLP-1 receptor agonists represents a ‘watershed moment’. They reduce body weight and lower blood glucose and cardiometabolic risk. GLP-1 receptor agonists, already transforming care in high-income countries, remain largely inaccessible in low- and middle-income settings, due to exorbitantly high costs.
These two inclusions signal that WHO is pushing for people-centred cardiovascular care and creating a pathway towards fairer pricing, generic and biosimilar production, and stronger advocacy for their inclusion in national lists.
Yet, the million-dollar question remains: does EML listing always translate into real-world access?
History suggests caution. When cardiovascular polypills—SPCs involving blood pressure- and cholesterol-lowering medicines with or without aspirin—were included in the 23rd Model EML, we expected their global uptake to improve rapidly. Yet more than two years later, not a single country has added them to its own national list. Even the simpler two-drug SPCs, included back in 2019, have been adopted only by a handful of countries.
The ground reality has not changed either. A survey of public and private sector facilities before the EML listing, showed poor availability of polypills. Early findings of an ongoing multi-country global survey on suggest that the access situation has barely changed following the EML listing. WHF’s recent Roadmap on SPCs highlight the persistent barriers that continue to plague its uptake, strongly advocating for countries to ensure adoption.
GLP-1 agonists may also face similar hurdles. Like many anticancer medicines, their high costs spark similar debates: are these medicines truly relevant for LMICs if patients and health systems still can’t afford them?
Being on the WHO EML is a start—but the real challenge is to ensure national adoption and implementation through adequate financing, education, and primary care integration.
Large-scale programs have demonstrated potential to penetrate primary care. HEARTS—a standardized, evidence-based clinical pathway now implemented in about 40 countries globally to manage hypertension and CVD risk—has successfully rendered SPCs more accessible and affordable through easy-to-follow protocols for primary healthcare professionals. The program proves how better pricing negotiations, strong political commitment involving ministries, and sharp focus on primary health services, can expand the uptake of essential medicines in LMICs.
Every year of delay means millions of lives lost to preventable cardiovascular diseases. Translating EML into lives saved worldwide therefore remains a collective responsibility. This is an urgent call for governments, payers, and procurement bodies to act quickly to ensure these medicines are not just essential on paper, but available in clinics and pharmacies globally.
WHF will continue to push for this system-level adoption—because the fight against the world’s largest killer and its silent accomplices simply cannot wait.
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