The survival penalty: Age-based inequities in hypertension and diabetes management in African health systems (1990–2022) – a secondary quantitative analysis

Africa is experiencing rapid population ageing, yet many health systems remain oriented towards acute and infectious disease care. Whether population-level indicators of hypertension and diabetes management remain comparable across older age groups is unclear. We assessed age-associated differences in chronic disease care cascade indicators across African Union member states using age-stratified estimates from the NCD Risk Factor Collaboration (NCD-RisC). We analysed country-year estimates for hypertension (1990-2019) and diabetes (1990-2022), comparing a working-age reference group (50-54 years), a young-old group (65-69 years), and the oldest available age groups (75-79 years for hypertension and ≥85 years for diabetes). Outcomes included diabetes treatment coverage, hypertension diagnosis, treatment and control, and the prevalence of severe untreated hypertension (stage 2; BP > 160/100 mmHg). The analysis included NCD-RisC estimates derived from 2,309 population-based studies involving 245 million participants. Hypertension prevalence was higher in adults aged 75-79 years than those aged 50-54 years (64·4% vs 42·6%; relative risk 1·51). Although diagnosis was more frequent among older adults (53·3% vs 42·6%), hypertension control remained lower (11·6% vs 16·9%). Diabetes treatment coverage declined after age 70, falling from 32·9% in adults aged 65-69 years to 23·1% in those aged ≥85 years (difference 9·8 percentage points; 95% UI 5·9-13·7). Severe untreated hypertension was more common in adults aged 75-79 years than in those aged 50-54 years (29·8% vs 26·6%), with the highest prevalence in Central and West Africa. Across Africa, diabetes treatment coverage and hypertension control declined with advancing age despite higher diagnosis rates, while severe untreated hypertension remained common among older adults. These findings support incorporating age-specific chronic disease cascade indicators into Universal Health Coverage monitoring and strengthening health systems to improve cardiovascular risk management in ageing populations.