A) Is the "triple approach" combining intervention by 1) home health education (HHE) by trained community workers plus 2)trained government primary health center mid-level providers (MLP) led care plus 3) trained private practitioners better thanthe "dual approach" (1 and 2 only), and better than no intervention (or usual care) in lowering blood pressure (BP) amongadults with hypertension in rural communities in Pakistan and Sri Lanka?B) Is the "dual approach" (1 and 2) better than no intervention (or usual care) in lowering BP among adults withhypertension in rural communities in Pakistan and Sri Lanka?C) Are the above-mentioned triple and dual approach incrementally cost- effective in terms of cost per projectedcardiovascular disease disability adjusted life-years (CVD DALYs) averted from the societal, government and participants'perspectives?The ancillary research question is:D) Are either of the above-mentioned triple or dual approach interventions better than usual care, and is triple approachbetter than dual approach in reducing left ventricular mass among adults with stage 2 systolic hypertension (systolic BP >=160 mm Hg) in rural communities in Pakistan and Sri Lanka? Cardiovascular disease (CVD) has become the leading cause of mortality worldwide, accounting for 30% of deaths even inlow- and middle- income countries (LMICs). In South Asia, high rates of CVD are observed at a younger age than in othercountries, causing a greater loss of productive life years with severe economic consequences. High blood pressure (BP)confers the greatest attributable risk to death and disease associated with CVD.Our Wellcome Trust funded Control of Blood Pressure and Risk Attenuation (COBRA) trial (2004 to 2007) in Karachi,Pakistan, suggested the combined strategy of family based home health education (HHE) delivered by trained communityhealth workers (CHW) plus care of patients by trained private general practitioners (GP) to optimally manage hypertensionhad the most marked beneficial impact on BP compared to usual care, or single interventions. However, the COBRAintervention was designed for an urban South Asian setting, where private GPs cater to over 75% of the patients seekingcare. Therefore, the trial did not use the public health infrastructure per se, nor did it evaluate whether mid-level providers(MLP) can deliver first steps of hypertension care including prescribing first and second line anti-hypertensive medications.Most of South Asia is still rural (64% Pakistan, 85% Sri Lanka) where prevalence of hypertension is high and healthcareinfrastructure and provider characteristics are very different compared to the urban setting. About 40-50% patients in ruralPakistan and Sri Lanka seek care (including prescription medications) from MLPs (visiting nurse, dispenser, assistantmedical officer) at the government community clinics. Thus whether hypertension management by this cadre of MLPs iseffective, especially when rolled out using government healthcare infrastructure is not known. Our proposed study isdesigned to answer this question in rural Pakistan and Sri Lanka.We propose a cluster RCT in 30 rural communities in Pakistan and Sri Lanka including 2500 individuals with hypertensionwith 2 year follow-up to evaluate the effectiveness of "triple approach" of combining intervention by 1) HHE plus 2) trainedgovernment primary health center MLP plus 3) trained private practitioners or "dual approach" of combining intervention of1 and 2 only compared to no intervention (or usual care) on lowering blood pressure, and to determine whether theseapproaches are incrementally cost-effective.The delivery of care by the various public providers and the private sector is now recommended by the World HealthOrganization in several communicable disease control programs, such as Directly Observed Treatment (DOTS) fortuberculosis and management of malaria. However, evidence on the effectiveness of using the same platform for chronicnon-communicable disease management is rather scarce.Moreover, wider discussion among the relevant stakeholders in South Asia to refine and implement the proposed activitieswould be beneficial, and would increase the likelihood of up-scaling the cost-effective strategies which could also beextended to other chronic diseases (and even infectious diseases) in an integrated manner that is potentially sustainableand applicable in rural settings across many Asian countries with similar ethnic populations and healthcare infrastructure.Comparing and contrasting the experiences from Sri Lanka and Pakistan should also provide valuable lessons not only forthese two countries but also for other countries in the region and beyond.