India needs a new healthcare model to effectively manage hypertension

Success will help in reducing government spending for the poor battling the cost of treating non-communicable diseases

At age 54, with family history and other associated risk factors and being well informed about the disease burden, I could not imagine suffering from hypertension. It was when I was accompanying my father in law , a cardiologist disclosed that this silent killer had taken me in its grip and prescribed a single dose of medicine. I continued on the single dose until this winter when a friend and well-known cardiologist advised me to regularly monitor my BP, resulting in one more medicine being added to my regimen. Thanks to these two doctors for timely diagnosis and advise otherwise it may have caused something more serious.

This story of mine can be well explained by ‘rule of halves’, which states that: 'half the people with high blood pressure are not known (“rule 1”), half of those known are not treated (“rule 2”) and half of those treated are not controlled (“rule 3”).

There’s consensus among health professionals that hypertension is definitely a public health issue because it contributes to the burden of heart disease, stroke, kidney failure and premature mortality and disability. The estimates say that one in every four deaths in India is contributed by cardiovascular diseases. Every fourth individual in India aged above 18 years has hypertension.

As per National Sample Survey Office (NSSO) 75th round (2017-18), the average medical expenditure per treated spell of hypertension (in the last 15 days) is Rs 399. Non-communicable diseases (NCDs), which includes hypertension, have a significant effect on the Indian economy. It is estimated that every 10 per cent increase in NCDs mortality results in 0.5 per cent reduction in annual economic growth.

There is consensus among public health professionals that early detection of hypertension, timely treatment along with adherence and self-care has significant benefits. Interventions must be easily accessible, affordable, sustainable and effective. Health outcomes of hypertension patients can be improved by strengthening prevention, increasing coverage of health services and reducing the suffering associated with high levels of out-of-pocket expenditure (OOPE).

There is also agreement that a vertical programme focusing on hypertension control alone cannot be cost effective and an integrated NCD programme implemented through a primary health care approach can offer affordable and sustainable solutions.

Through this article, I am suggesting an Indian model of effectively managing hypertension. A model which has learnings from providing basic packages of primary healthcare through a network of Ayushman Bharat Health & Wellness Centres; a model which has basic technology embedded in the core principles of National Digital Health Mission; a model which takes advantage of availability of good quality inexpensive generic medicines in the country and a model which follows the ethos of National Health Mission for financing and governance. A model suggesting two different approaches for rural and urban areas, but keeping basics the same.

In rural India, the line listing by ASHAs using Community Based Assessment Checklist (CBAC) can be the starting point. Through this population can be segregated as suspected, on treatment , at risk and not at risk. Suspected cases would need to be confirmed with the disease by the primary healthcare team. Confirmed cases would need to ensure treatment adherence with regular follow ups. Those at risk should be regularly screened once a year. Remaining others can be screened once in two years.

Effective referral mechanisms would be important, so that people can be managed based on their level of risk. Return referrals by such specialists to primary healthcare teams would also be necessitated for providing medicine, ensuring treatment compliance and monitoring outcomes.

However, in urban India, primary health care service delivery through health and wellness centres is not well established. Then in urban areas more than half of the OPD consultation is with the private sector. Adding to complexity is different health service delivery mechanisms. Therefore, thinking of a well-structured referral mechanism would be only wishful. However, this complexity can effectively be managed by ensuring a process of mandatory enrolment of all patients, similar to one adopted for Covid-19 vaccination in India. These patients would be able to access their prescriptions and to get medicines, would have flexibility to go to the Health & Wellness centres, Jan Aushadhi Kendra or even can be provided with e Rupee vouchers, if they are willing to procure generic medicines.

Then there would be a compelling need to gradually increase coverage of the whole population by further strengthening suggested mechanisms and bringing all patients in the monitoring network.

Finally, National Digital Health Mission (NDHM) has started working on war footing for creating individual based ABHA IDs, along with a registry of all health professionals and both public and private health institutions. This work of NDHM would provide the required spine to make the programme stand up on its own, right from planning to monitoring stages and also identifying people at risk using artificial intelligence.

I am sure that Team Health India can easily shift the hypertension pattern of the community which currently leans more towards the traditional ‘Rule of Halves’ to ‘Rule of Three- Quarters’, where at least 75 percent of hypertensive would be detected early, would have access to adequate treatment and will have good control of their hypertension.

In the meanwhile, measure like excise tax increase on tobacco and alcohol, ban on advertising (including surrogate one) of tobacco, alcohol and junk food, reducing salt content in processed foods, replacement of trans fat with polyunsaturated fat and public awareness programs about healthy diet and physical activity will be needed to be taken on priority which are imminent.

If we are able to do this, then it will help in reduction of government spending to protect economically weaker sections from the catastrophic cost of treating NCDs. This will again prove to be an Indian cost effective model for the entire world to emulate.

(Dr Manohar Agnani is a public health expert, author, and retired IAS officer. The views expressed are personal.)