Hypertension control rates are unacceptably low in China. The present study demonstrates if a customized, guideline-oriented training program can cost-effectively improve hypertension management in primary healthcare. Four typical community health centers in Beijing were selected and randomized to intervention or control (one urban and one rural each). A sample of 140 patients with hypertension and blood pressure uncontrolled was recruited from each center. Primary healthcare providers in intervention centers provided management to the recruited patients for 1 year after receiving training with customized hypertension management guidelines, and primary healthcare providers in control provided with usual care. Intention-to-treat analysis showed that hypertension control (systolic blood pressure (SBP) <140 mm Hg and diastolic blood pressure (DBP) <90 mm Hg)) rate was significantly higher in interventions than controls at month 3 (42.1% vs. 34.3% in urban and 30.7% vs. 10.0% in rural centers) and the trend increased to month 12 (70.7% vs. 40.0% in urban and 72.9% vs. 27.9% in rural); P-values by logistic mixed model were all <0.001 for both urban and rural after adjustment for baseline multiple variables including blood pressure. Mean reductions of SBP and DBP were significantly larger in interventions. The intervention was cost-saving, with an average incremental cost-saving of US$ 20.3 per patient in urban sites and $ 7.0 per patient in rural sites. Corresponding results from per-protocol analysis were very similar. The customized, guideline-oriented hypertension management program in primary healthcare in China effectively improved blood pressure control and was cost-saving. Hypertension Research (2013) 36, 313-321; doi: 10.1038/hr.2012.173; published online 15 November 2012