Introduction Hypertension has become a major cause of morbidity and premature mortality in South Africa, but population-wide estimates of prevalence and access to care are scarce. Using data from the South African National Health and Nutrition Examination Survey (2011–2012), this analysis evaluates the national prevalence of hypertension and uses a care cascade to examine unmet need for care.

Methods Hypertension was defined as blood pressure over 140/90 mm Hg or use of antihypertensive medication. We constructed a hypertension care cascade by decomposing the population with hypertension into five mutually exclusive and exhaustive subcategories: (1) unscreened and undiagnosed, (2) screened but undiagnosed, (3) diagnosed but untreated, (4) treated but uncontrolled and (5) treated and controlled. Multivariable logistic regression models were used to explore factors associated with hypertension prevalence and diagnosis.

Results In South Africans aged 15 and above, the age standardised prevalence of hypertension was 35.1%. Among those with hypertension, 48.7% were unscreened and undiagnosed, 23.1% were screened but undiagnosed, 5.8% were diagnosed but untreated, 13.5% were treated but uncontrolled and 8.9% were controlled. The hypertension care cascade demonstrates that 49% of those with hypertension were lost at the screening stage, 50% of those who were screened never received a diagnosis, 23% of those who were diagnosed did not receive treatment and 48% of those who were treated did not reach the threshold for control. Men and older individuals had increased risks of being undiagnosed after controlling for other factors.

Conclusions There is significant unmet need for hypertension care in South Africa; 91.1% of the hypertensive population was unscreened, undiagnosed, untreated or uncontrolled. Data from this study provide insight into where patients are lost in the hypertension care continuum and serve as a benchmark for evaluating efforts to manage the rising burden of hypertension in South Africa.