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Original research article
Cardiac rehabilitation delivery in low/middle-income countries
  1. Ella Pesah1,
  2. Karam Turk-Adawi2,
  3. Marta Supervia3,4,
  4. Francisco Lopez-Jimenez4,
  5. Raquel Britto5,
  6. Rongjing Ding6,
  7. Abraham Babu7,
  8. Masoumeh Sadeghi8,
  9. Nizal Sarrafzadegan8,16,
  10. Lucky Cuenza9,
  11. Claudia Anchique Santos10,
  12. Martin Heine11,
  13. Wayne Derman11,
  14. Paul Oh12,
  15. Sherry L Grace12
  1. 1 School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
  2. 2 Department of Public Health, Qatar University, Doha, Qatar
  3. 3 Department of Physical Medicine and Rehabilitation, Gregorio Marañón General University Hospital, Madrid, Spain
  4. 4 Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
  5. 5 Department of Physiotherapy, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  6. 6 Department of Cardiology, Peiking University People’s Hospital, Beijing, China
  7. 7 Department of Physiotherapy, Manipal University, Manipal, Karnataka, India
  8. 8 Department of Cardiology, Isfahan University of Medical Sciences, Isfahan, Iran
  9. 9 Department of Adult Cardiology, Philippine Heart Center, Quezon City, Philippines
  10. 10 Division of Cardiovascular Diseases, Cardiac Rehabilitation, Mediagnóstica Duitama, Boyacá, Colombia
  11. 11 Institute of Sports and Exercise Medicine and Department of Physiotherapy, Stellenbosch University, Stellenbosch, South Africa
  12. 12 Cardiovascular Rehabilitation, University Health Network – Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada
  13. 16 School of Population and Public Health, University of British Columbia, Vancouver, Canada
  1. Correspondence to Dr Sherry L Grace, Faculty of Health, York University, Toronto, Ontario M3J 1P3, Canada; sgrace{at}


Objective Cardiac rehabilitation (CR) availability, programme characteristics and barriers are not well-known in low/middle-income countries (LMICs). In this study, they were compared with high-income countries (HICs) and by CR funding source.

Methods A cross-sectional online survey was administered to CR programmes globally. Need for CR was computed using incident ischaemic heart disease (IHD) estimates from the Global Burden of Disease study. General linear mixed models were performed.

Results CR was identified in 55/138 (39.9%) LMICs; 47/55 (85.5% country response rate) countries participated and 335 (53.5% programme response) surveys were initiated. There was one CR spot for every 66 IHD patients in LMICs (vs 3.4 in HICs). CR was most often paid by patients in LMICs (n=212, 65.0%) versus government in HICs (n=444, 60.2%; p<0.001). Over 85% of programmes accepted guideline-indicated patients. Cardiologists (n=266, 89.3%), nurses (n=234, 79.6%; vs 544, 91.7% in HICs, p=0.001) and physiotherapists (n=233, 78.7%) were the most common providers on CR teams (mean=5.8±2.8/programme). Programmes offered 7.3±1.8/10 core components (vs 7.9±1.7 in HICs, p<0.01) over 33.7±30.7 sessions (significantly greater in publicly funded programmes; p<0.001). Publicly funded programmes were more likely to have social workers and psychologists on staff, and to offer tobacco cessation and psychosocial counselling.

Conclusion CR is only available in 40% of LMICs, but where offered is fairly consistent with guidelines. Governments should enact policies to reimburse CR so patients do not pay out-of-pocket.

  • cardiac rehabilitation
  • health care delivery
  • global health
  • acute myocardial infarction

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Cardiovascular disease (CVD) is one of the leading causes of disability globally,1 and the highest mortality and morbidity rates are found in low/middle-income countries (LMICs).2 The economic burden of CVD is estimated to decrease gross domestic product by ~7% in these countries.3 Of the ~200 countries globally, 140 (69.0%) are LMICs,4 and therefore there is great need for cost-effective CV secondary prevention in many countries.

Cardiac rehabilitation (CR) is a proven model of care for secondary prevention. It is comprised of several core components, delivered by a multidisciplinary team.5 Participation in CR reduces CVD mortality and hospital readmission by ~20%, as well as improves quality of life,6 with more CR associated with better outcomes. Accordingly, it is a recommendation in clinical practice guidelines for CVD,7 revascularisation8 9 and heart failure (HF)10 patients. Unfortunately, however, it is grossly under-used, particularly in LMICs where CVD is at its’ worst.11 12 This is despite that the WHO recommends CR as a priority intervention for prevention and control of CVD,13 and their rehabilitation 2030 call to action (

A review of literature revealed CR exists in only 23% of LMICs11; however, to our knowledge there has been no primary study to ascertain availability in LMICs. Moreover, our recent review of the literature14 revealed there have only been four publications describing the nature of CR programmes in LMICs15–18; these publications describe CR in only 10 (18.2%) of the 55 LMICs known to have CR. What is known is largely concentrated in the Latin American region, and results suggested differential costs by funding source, with many patients paying out-of-pocket. But considerable consistency in the nature of healthcare professionals (HCPs) on the CR team, accepted indications and delivery of core components was found. Therefore, the objectives of this study were to characterise the: (1) availability and density of CR, (2) nature of CR programmes, as well as (3) barriers to CR delivery in LMICs, and compare these (a) to high-income countries (HICs) and (b) by funding source.


Design and procedure

This research was quantitative and cross-sectional in design.

Study methods are outlined in detail elsewhere.19 20 In brief, first, a list of all countries globally was compiled. Whether CR services were available in each country or not was ascertained through previous reviews,11 12 communication with major CR and cardiology societies, key informants and the web.

For each country identified to offer CR, identified leaders were sent an email requesting their collaboration to: (1) identify the total number of programmes in their country and (2) administer the survey to each programme identified.

The lead clinician at each programme identified was emailed requesting their completion of the survey. Informed consent was secured through an online form. Data were collected through Research ElectronicD ata Capture (REDCap) from June 2016 to July 2017.


The sample consisted of all CR programmes identified in the world, that offer services to patients following an acute cardiac event or hospitalisation (ie, phase II). The inclusion criteria were CR programmes that offered: (1) initial assessment, (2) structured exercise (supervised or not) and (3) at least one other strategy to control CV risk factors. All programmes were contacted in countries known to have ≤350 CR programmes. Where more existed, a random subsample of 250 were contacted.


Development of the survey is described in detail elsewhere,21 and it is available elsewhere.19 In short, items were based on previous national/regional CR programmes surveys.16 22 23 Items included country, programme funding source, capacity, HCPs on the CR team, accepted indications, elements delivered, dose, barriers to delivery, as well as delivery of alternative models.

Country income classification was defined based on World Bank definitions of gross national income per capita: high income was US$12 236 or more; lower-middle income was US$1006–3995; upper-middle income US$3996–12 235; low income was US$1005 or lower.4

Programme capacity was defined as the median number of patients a programme could serve annually; this was also multiplied by the number of programmes in the country (ascertained from champion) to determine national CR capacity. National density was national capacity divided by 2016 estimated incidence of ischaemic heart disease (IHD) (ascertained from Global Burden of Disease study).24 Finally, unmet need was number of incident IHD patients minus number of spots/year (ie, capacity).

Respondents were provided five options for funding sources, and instructed to check all that apply. ‘Other’ responses were categorised, and classified as private or public sources (eg, foundations classified as private). To categorise funding source, respondents who selected the ‘patient’ and/or ‘private health insurance’ options only were categorised as ‘private’; those who selected the ‘social security/government’ and/or ‘hospital/clincial centre’ options only were classified as ‘public’; those who selected one or more of both the above private and public response options were categorised as ‘hybrid’. National funding source was also computed, classified as the most frequent of the three options from all responses in a given country. Costs were converted using purchasing power parity conversions (US$2016).25

Data analysis

IBM SPSS V.24 were used for analysis, and p<0.05 considered significant. All initiated surveys were included. The number of responses for each question varied due to missing data (eg, respondent did not answer a question due to lack of willingness or potential inapplicability, use of skip logic); for descriptive analyses, percentages were computed with the denominator being the number of responses for a specific item.

Descriptive statistics were applied for all closed-ended items in the survey. All open-ended responses were coded/categorised. The nature of CR services and barriers were compared by country income classification and funding source via generalised linear mixed models where possible (treating country as a higher-order variable), otherwise bivariate analyses were computed as applicable (eg, χ2 tests); non-parametric tests were used where variables were not normally distributed (ie, Mann-Whitney U).


As shown in online supplementary table 1 and figure 1, 55/138 (39.9%) LMICs in the world were found to offer CR, of which data were collected in 47 (85.5% country response rate). Of these, 2 (of 5 low income countries(LICs) with CR; 40.0%) were LICs, 15 (of 17; 88.2%) were lower-middle incomecountries (MICs) and 30 (of 33; 90.9%) were upper-MICs. Overall, 335 (53.5% programme response rate; shown by income classification in online supplementary table 1) surveys were initiated in LMICs, and 747 (27.2% response) in HICs (see Supervia Pola et al 19). There was a mean of 6.1±13.3 (SD; median=1) surveys per LMIC.

Supplemental material

Figure 1

Most common CR funders in low/middle-income countries*. *Based on most frequent of the three funding sources. CR, cardiac rehabilitation.

CR density in LMICs

The year the first programme was initiated by country is reported elsewhere,19 with the first programme opening in a LMIC in 1944 in Mexico, and 240 (77.4%) programmes in LMICs opening since 2000 (of which 78 were in China). Worldwide, CR exists in 56 (86.2%) of the 67 HICs (this is significantly greater than LMICs; χ2=37.3, p<0.001), 49 (47.1%) of the 106 MICs, and in 5 (16.7%) of the 30 LICs (online supplementary table 1).

National CR density was also reported elsewhere (in countries where CR exists; IHD incidence in countries without CR (ie, no density) is also shown there).20 Results showed wide variability across LMICs, with on average one spot per 53 incident IHD patients (308 in LICs, 274 in lower-MICs and 30 in upper-MICs). Density was greatest in Georgia (one CR spot per two incident IHD patients) and lowest in Nigeria (one spot per 4480). Median national density in HICs was one spot per five patients. The ranking of countries based on CR density is also shown elsewhere (lower scores reflective of better density)20; of 86 countries with data available, the mean rank for LICs was 66, and 61 for MICs. The top 25 countries were all HICs, except the following 3 MICs: Georgia (8th), Argentina (17th) and Colombia (22nd). Overall, counting zero spots for LMIC countries without CR, there was on average one CR spot per 66 incident IHD patients across all LMICs. Online supplementary table 1 also displays unmet CR need.

CR indications accepted

The three most commonly accepted indications (acute coronary syndrome and revascularisation patients) were consistent in LMICs and HICs, and with guidelines (HF~90%; online supplementary table 2; data shown by country elsewhere).19 Valve procedures and heart transplant patients were significantly more likely to be accepted by programmes in HICs than LMICs, and rheumatic heart disease was more-readily accepted in LMICs.

Three-quarters of programmes in LMICs accepted patients at high-risk of CVD or with diabetes as a primary indication (online supplementary table 2). Programmes in LMICs were significantly more likely to accept these primary diagnoses, as well as patients with lung disease than programmes in HICs. Other accepted indications reported by programmes in LMICs were syncope (n=19, 29.2%), bariatric/obesity (n=16, 24.6%) and kidney disease (n=7, 10.8%) patients.

CR providers

The most commonly reported responsible clinician was some type of physician (eg, cardiologist, physiatrist, sports medicine) in 254 (81.3%) LMIC programmes, and in 428 (63.7%) HIC programmes (χ2=31.45, p≤0.001). The most commonly present HCP type during exercise sessions was physiotherapists (n=185, 72.0%) in LMICs, and in HICs (n=392, 73.3%). The most common HCPs found on CR teams in LMICs were cardiologists, nurses and physiotherapists; in HICs this was nurses, dietitians and physiotherapists (online supplementary table 3; data shown by country elsewhere).19 Two-thirds of programmes had an administrative assistant, and one-fifth a community healthcare worker. Fifty-seven (19.0%) programmes had some type of mental health professional (ie, psychologist, psychiatrist or social worker). Other HCPs on the CR team were physicians of other specialties (n=14, 21.2%), other allied HCP (n=9, 13.6%) and generalist physicians (n=8, 12.1%). CR programmes in LMICs were significantly more likely to have physicians on staff, whereas in HICs were significantly more likely to have nurses, dietitians, social workers, pharmacists and administrative assistants on the CR team than LMICs. Programmes on average had six HCPs, with no significant difference by country income classification.

CR elements

Elements delivered are shown in online supplementary table 4 by country income classification (data shown by country elsewhere).19 Initial assessment was the most frequently delivered core component (reflective of inclusion criteria), followed by management of cardiovascular risk factors and patient education in LMICs; this was similar in HICs. Eighty per cent of programmes offered supervised exercise training.

Initial functional capacity assessment was more commonly by a stress test in LMICs, but not in HICs. Depression screening, nutrition counselling, stress management, tobacco cessation interventions, return-to-work counselling and communication with the primary care provider were provided significantly more often by programmes in HICs, with a significantly greater number of core components delivered in HICs than LMICs (although programmes in LMICs more often offered other elements such as family education, and complementary/complementary medicine). Patients were significantly more likely to have an individual consult with a physician in LMICs, but with a nurse in HICs. There was more follow-up post-program in LMICs than HICs, and a trend towards more women-only classes (almost one in five programmes).

CR dose

Table 1 shows the greater session frequency, and hence total number of sessions and overall ‘dose’ in CR programmes in LMICs compared with HICs. Median hours/programme was 26.5 (Q25–Q75=10–42) in LMICs.

Table 1

Mean cardiac rehabilitation dose (±SD) by country income classification and funding source, n=1082

Alternate models of CR delivery

Sixty-six (21.5%) programmes in LMICs offered an alternative model of CR delivery than supervised clinic-based care, and 219 (36.0%) programmes in HICs offered them (p<0.31).

Barriers to CR delivery

What resources programmes would need in order to increase capacity for both home-based and community-based programmes are shown in figure 2. Table 2 displays programme ratings of barriers to delivery of all models faced by CR programmes in LMICs and HICs.

Figure 2

Resources required to increase alternative model delivery capacity in low/middle-income countries.

Table 2

Barriers to cardiac rehabilitation delivery by income classification and funding source, n=1082

Costs and sources of funding for CR

Respondents were requested to estimate the cost to treat one patient for a full programme. Using purcahing power parity(PPP), the median cost was US$718.24 (Q25–Q75=US$337–1232) in LMICs and US$1267 (Q25–Q75=US$581–2427) in HICs (Mann-Whitney U, p<0.001).

Figure 1 displays the most common source of funding for CR by country in LMICs (reported by country elsewhere).26 Funding sources in LMICs and HICs are summarised in table 3. Significantly more programmes were funded by patients or private health insurance in LMICs than HICs, with more programmes funded by clinical centres in HICs. Other sources of funding were also more common in HICs, which included research funding/universities, veteran programmes and charity foundations.

Table 3

Sources of cardiac rehabilitation programme funding by country income classification, n=1082

As shown, patients were the most common CR payers in LMICs, paying some or all of the programme cost (mean=49.3%±38.4%) in two-thirds of programmes. Using PPP, the median cost to patients for a complete programme when they paid was US$338.29 (Q25–Q75=US$101–814) in LMICs and US$244.86 (Q25–Q75=US$142–596) in HICS (p=0.72; not taking into consideration transportation costs or time off work).

Online supplementary tables 2–4 and tables 1–3 display CR programme characteristics by funding source in LMICs. As shown in online supplementary table 2, there were no significant differences in cardiac indications accepted by funding source, but privately funded programmes were significantly more likely than public programmes to accept high-risk primary prevention patients. As shown in online supplementary table 3, in terms of HCPs on staff, publicly funded programmes had significantly more psychologists, pharmacists and social workers, and privately funded programmes had more administrative assistants.

As shown in online supplementary table 4, privately funded programmes were significantly more likely than public programmes to communicate with a patients’ primary care provider and offer resistance training; however, they were least likely to offer tobacco cessation interventions. Public programmes were significantly more likely than private programmes to offer individual consults with a nurse and psychological counselling. There were no differences observed in total elements offered by funding source.

As shown in table 1, publicly funded programmes were of significantly longer duration than those funded by other means, resulting in significantly greater overall CR dose. Finally, as shown in table 2, patient referral was a significantly greater barrier in privately funded programmes, while publicly funded programmes experienced significantly more human, space and equipment barriers.


CR supply in LMICs is poor, with only ~40% of LMICs having any CR programmes (with particularly low availability in LICs (only 5 programmes globally, and hence results are primarily generalisable to MICs) and Africa (only 32 programmes)). Where it is found, there is grossly insufficient capacity to meet the burden of disease. Available CR programmes in MICs offer fewer core components; return-to-work counselling, stress management and tobacco cessation interventions services should be offered more universally, particularly as they would be highly relevant to patients in LMICs. Programmes in MICs had on average six staff, most commonly cardiologists, nurses, physiotherapists and dietitians, offering on average 33 hours of CR to each patient over 3 months.

Of the 92 countries globally without CR, over 90% are LMICs. Across all LMICs, 14 766 930 more CR spots are needed annually to treat all incident IHD cases (vs only ~3.5 million needed across HICs),20 and even more spots would be needed to treat those with HF, among other indications. While IHD burden is still lower in LMICs than HICs, it is rapidly increasing. Clearly capacity needs to be increased. It was surprising that the programmes that do exist were so comprehensive, and expensive (eg, more use of stress tests, physicians), with a comparable staffing complement to HICs (ie, number), as it was expected programmes would be delivering the basics in an affordable manner so as to be feasible and reach as many patients as possible. This could be due to the methods of programme identification in the study, or the motivation of profit given programmes are more often privately funded.

While there was a comparable number of staff on CR teams in HICs and MICs, the type of staff differed, with in particular more physician contact in MICs. This could be due to lower labour costs in LMICs, or that it is cardiologists who have the capability/resources/position of opening programmes in these settings. While some guidelines recommend physicians be a major part of CR team, not all do.5 Task-shifting represents an important avenue to reduce the cost of CR delivery in LMICs. The International Council of Cardiovascular Prevention and Rehabilitation offers a certification programme for teaching students, community healthcare workers and regulated HCPs alike how to deliver all core components in low-resource settings (

Cost to deliver CR was significantly lower in MICs compared with HICs (consistent with most healthcare costs),27 yet still does not appear affordable when juxtaposed against healthcare expenditure per capita in LMICs which is US$455.39.28 Patients paid part of the cost of CR in two-thirds of programmes, with the average cost to patients being US$570.32 PPP/programme. Given the median annual income in LMICs is US$833 (2013 purchasing power parity),29 this is unaffordable. This would lead to physician failure to refer, which was the most common CR barrier in LMICs (as also reported in a recent review),12 as well as failure of patients to initiate CR or where they do, to dropout (such that although a higher dose of CR is prescribed in LMICs, patients are likely actually receiving a much lower dose). Indeed, patient or private funding sources were significantly more common in LMICs than HICs, consistent with the fact that there is more public funding of health systems in HICs than LMICs.27 Funding source had an impact on indications accepted (non-cardiac), dose, as well as type (but not total number) of HCPs on staff, and components offered. Publicly funded programmes do appear to be of higher quality in terms of structure. Clearly, advocacy for public reimbursement is much needed.30


First, some programmes may not have been identified, especially in LICs where they may not have a website or published research, and in countries where no society or champion was identified. Therefore, availability, capacity and density could be somewhat under-estimated. Moreover, due to our inclusion criteria and definition of CR (which stem from HICs), chronic disease management programmes or clinics which are less comprehensive (eg, no exercise) would not be represented. Second, though a high response rate at the country-level of 85% was achieved, response rates among programmes within LMICs was just over 50%, and hence there may be some bias. However, the response rate is considered quite good for online surveys, and ultimately the sample was comprised of over half of CR programmes in LMICs globally.

Third, related to measurement, information on programmes was reported by staff, and while responses were confidential, respondents may have responded in a manner that reflected what they know is recommended in guidelines (ie, socially desirable responding). So, for example, the number of elements delivered may be higher than reality. Moreover, while the survey was pilot tested, items were not validated through verification of responses in a random subsample of programmes. The cost items in particular should be interpreted with caution. They were not sufficiently detailed to capture what types of costs respondents included in their estimates and how they were counted, and again were not validated against actual costs.

Finally, results of the study cannot be used to draw conclusions regarding whether the programmes as delivered improve patient outcomes, as that would require investigation of patient-level data. Only the structure and processes of programmes were considered.

In conclusion, CR remains largely unavailable in the majority of LMICs. Where it exists, CR is quite consistent with guideline recommendations even from HICs, but is largely inaccessible to patients for reasons of capacity and finance. Increasing CR reimbursement, task shifting, as well as offering more home-based programmes could mitigate these barriers.

Key messages

What is already known on this subject?

  • There have been only four studies that have investigating the nature of cardiac rehabilitation (CR) in low/middle-income countries (LMICs), mainly in the Latin American and Caribbean region.

What might this study add?

  • This is the first study to ascertain the availability of CR in LMICs. Results indicated CR is only available in 40% of LMICs, but where offered is fairly consistent with guidelines.

How might this impact on clinical practice?

  • More programmes are required to meet the growing need for cardiovascular disease care in LMICs. CR should be reimbursed to adequate levels to ensure delivery of all core components, by a reliable non-patient source.


On behalf of the International Council of Cardiovascular Prevention and Rehabilitation through which this study was undertaken, the Global CR Programme Survey Investigators are grateful to all other national champions who collaborated to identify and reach programs in their low/middle-income country or region, namely, Eduardo Rivas-Estany, Richard Salmon, Lela Mashkhulia, Basuni Radi, Hermes Lomeli, Eleonora Vataman, Rosalia Fernandez, Voja Giga, Aashish Contractor and Jamal Uddin. We thank the Statistical Consulting Service of the Institute for Social Research, York University for statistical help and advice. We also thank the following associations for assisting with programme identification: the Africa Heart Network, the Brazilian Society of Cardiorespiratory Physiotherapy, the International Society of Physical and Rehabilitation Medicine and the World Heart Federation (who also formally endorsed the study protocol). WD reports some financial activities that were outside the submitted work.



  • Contributors SLG, FL-J, KT-A and MS conceived and designed the research. EP and SLG preformed statistical analysis and drafted the manuscript. SLG handled funding and supervision. All authors contributed to the acquisition of the data and made critical revisions to the manuscript. All gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.

  • Funding This project was supported by a research grant from York University’s Faculty of Health. Funding was used to translate the survey into Spanish and Chinese characters.

  • Competing interests WD received research grants from the International Olympic Committee and International Paralympic Committee and personal fees from the Adcock Ingram Pain Advisory Board and the Ossur South Africa Advisory Board.

  • Ethics approval The study was approved by York University’s Office of Research Ethics (Toronto, Canada; e2014-078) and Mayo Clinic’s Institutional Review Board (Rochester, United States; 16-001110). All participants gave informed consent before initiating the survey.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data will be available upon request and approval of the corresponding author SLG (

  • Patient consent for publication Not required.