The rapidly growing burden of non-communicable diseases (NCDs) in sub-Saharan Africa necessitates a better understanding of access gaps along the care continuum. This study assessed the prevalence and inequality in unmet need for hypertension and diabetes care in Tanzania, South Africa, and Lesotho using a care cascade framework.

We conducted a cross-sectional analysis of nationally representative Demographic Health Survey (DHS) datasets from Tanzania (2022), South Africa (2016), and Lesotho (2023/24), focusing on adults aged 15 years and older. The study estimated the proportion of adults with hypertension or diabetes who had not been screened, diagnosed, treated, or achieved disease control. Inequality was assessed using Erreygers Normalized Concentration Indices (ENCI), stratified by sex and residence.

Hypertension prevalence was 12.6% (95% CI: 11.7–13.4) in Tanzania, 46.7% (95% CI: 45.0–48.4) in South Africa, and 15.4% (95% CI: 13.8–17.2) in Lesotho. In Lesotho, 9.1% (95% CI: 7.8–10.6) of adults had diabetes. Unmet need was substantial across all countries: 96.5% for hypertension in Tanzania, 84.2% in South Africa, 65.8% in Lesotho, and 84.2% for diabetes in Lesotho. The care cascade framework revealed critical bottle-necks at screening and treatment stages. Inequality analyses revealed strong pro-poor gradients, particularly in screening (ENCIs: Tanzania −0.19, South Africa −0.17, Lesotho hypertension −0.15, Lesotho diabetes −0.24; all p < 0.01), with poor men experiencing the most disparities.

Substantial and inequitable gaps exist in hypertension and diabetes care. Policy strategies should prioritize community-based screening, primary care integration, and equity-focused interventions targeting poor men to improve NCD outcomes in the region.