PAUD, MAHARASHTRA STATE, INDIA – It is 11:15 on a Wednesday morning, and the March sun is hot but not yet punishing in this part of western India. Mathabai Jadhav, 65, waits patiently for her turn at the Paud Rural Hospital, some 30 kilometres from the city of Pune.

At least two dozen patients like her, mostly elderly women and men from nearby rural areas, are waiting. Some sit on benches balancing a walking stick against their legs, others on the floor. They are here to attend a “screening camp” for non-communicable diseases (NCDs) that is held every Wednesday morning at the hospital.

Four healthcare workers are in the midst of frenetic activity. One pricks patients’ fingers to draw blood and test sugar levels, another checks their blood pressure, the third dispenses government-subsidized medicines prescribed by hospital doctors and the fourth provides quick counselling on the dos and don’ts related to diet and exercise for better hypertension management.

Jadhav has lived with hypertension for nearly 14 years. “I found out when I came to the doctor regarding a wrist injury,” she said. For over a decade, she went to private practitioners but for two-and-a-half years now she has been a regular at the Rural Hospital where the medication is free.

Hypertension – a neglected condition

Hypertension, simply put, is when the pressure in the blood vessels is too high. The World Health Organization (WHO) estimates that over a billion adults between the ages of 30-79 live with hypertension. Around half of them never find out or are not treated for the condition.

This has grave consequences as hypertension is a leading single-preventable risk factor for cardiovascular disease (CVD) that killed an estimated 17.9 million people globally in 2019.

In India, 28% of adults (18+) suffer from hypertension, with 70% of cases undiagnosed, a recent large-scale study found. Moreover, 90% of those living with hypertension don’t get treatment, or their treatment is ineffective to keep their hypertension within normal range.

Strengthening programmes in LMICs 

In the past eight years, more than 40 low- and middle-income countries, including Bangladesh, Cuba, India and Sri Lanka, have strengthened their hypertension care, enroling more than 17 million people into treatment programmes based on a WHO-recommended package of primary health care interventions (HEARTS), according WHO’s first-ever global report on hypertension, released in September 2023 on the sidelines of the UN General Assembly.

Meanwhile, high-income countries such as Canada and South Korea have achieved blood pressure control in over 50% of adults living with the condition through delivery of comprehensive hypertension programmes, WHO found. The report followed up on implementation of the global WHO HEARTS initiative first launched in 2016.

India’s hypertension control initiative

In 2017, India, now the world’s most populous country, started the India Hypertension Control Initiative (IHCI). The pilot was rolled out across five states and reaching over 15,000 public health facilities, including primary health care centers and rural hospitals, by March 2022.

The programme relied on simple measures that can still be challenging to implement in low-resource settings: standardizing treatment protocols; ensuring the public healthcare system has the standard drugs to manage hypertension; equipping health centres with monitoring systems; and encouraging better digital or paper record-keeping to track patient progress.

Prabhdeep Kaur, the lead investigator of the IHCI told Health Policy Watch that the idea was to decentralize care and prioritize evidence-based strategies that are known to work. “Then implement them by working along with the governments on the ground and see what kind of results we get, what challenges are there, can they be scaled up or not,” she said.

This is the same approach recommended by the WHO, which has found that countries that strengthen primary healthcare (PHC) to improve hypertension management see a drop in CVD mortality as well.

WHO was also a partner of the IHCI, along with India’s premier medical research agency – the Indian Council of Medical Research (ICMR). The project received additional funding support from both the central and some state governments in India.

Reaching the global targets requires public and private collaboration  

WHO’s global target is to reduce hypertension by 33% between 2010 and 2030. WHO estimates that hypertension, as such, causes an estimated 10 million deaths annually.

India’s target is to reduce hypertension by a quarter by 2025, although the country has not specified a baseline year.

Getting there requires not just a nudge from the government but also active involvement of civil society and the private sector, which provides around 70% of the country’s healthcare services.

Two-pronged approach needed

While a third of all adults globally, and nearly one-third in India, have hypertension, almost another third also have pre-hypertension that requires regular monitoring, said Dr Sailesh Mohan, Professor at the research non-profit Public Health Foundation of India and Director of the Centre for Chronic Conditions and Injuries (CCCI).

“So there’s a large pool of people who are hypertensive and another pool waiting to convert to full-fledged hypertension from pre-hypertension,” he said.

If pre-hypertension is not addressed, it quickly progresses to hypertension, and managing it effectively requires a synergistic approach, he explained.

This approach involves promoting policies that reduce salt, tobacco and alcohol consumption, encourage and support an active lifestyle and healthier diet, as well as increase awareness about hypertension.

The health system also needs to be bolstered to screen patients for hypertension and provide evidence-based care.

Hypertension management in most cases requires regular monitoring, and a relatively cheap drug once a day, which can be done by trained nurses or healthcare workers.

Aruna Kaware, NCD counsellor at the Paud Rural Hospital said on average three-quarters of the patients are above the age of 60.

“We are able to handle most patients here. Around 10-20% of the patients might need to be referred to bigger hospitals,” she said.

The state of Maharashtra where the hospital is located, has done a good job of scaling up NCD care, said Kaur.

Detection is often the first challenge

The detection of hypertension can be a challenge as patients might not always have symptoms, which is why it is called “the silent killer,” explained Mohan.

Nathu Tonde, 83, now travels to the Rural Hospital every month alone to get this medication, using a cane for balance. But he came to the health centre for an unrelated ailment, and his hypertension was detected in a routine blood pressure measurement.

One of the striking results of the IHCI initiative was the increased accessibility of basic medications – due to a major reduction in drug stockouts, reduced to less than 5% in areas where the pilot was implemented. In addition, 47% of the 740,000 patients across 4,505 health facilities who took part in the project had their hypertension within the healthy limit during their visit in the first quarter of 2021.

Technically, the five-year initiative concluded in 2022. But Kaur, the lead investigator, said the partners in the original initiative are currently working with the state governments across India to make it sustainable, as well as scaling it up further.

Countering practical challenges – patient compliance and health system capacity 

While hypertension management is relatively easy in theory, there are other practical challenges.

“People are not compliant with the medication,” said Dr Arvinder Pal Singh Narula, Assistant Professor of Community Medicine at Bharati Vidyapeeth Medical College. A key reason, especially in rural areas, is either the distance or when medicines run out.

“My village is half an hour away and transport is hard to get,” Jadhav said of the monthly trips she makes to the health centre. It also costs money to make the trip.

Kaware, the NCD counselor, said that many elderly patients come unaccompanied like Tonde had, and it is hard to explain even the basics like which medicines to take and when.

India has long focused on improving healthcare delivery by working with community health workers.

More recently, states like Maharashta have countered the shortage of doctors and nurses in rural areas by engaging traditional medicine practitioners who are re-trained in “bridge programmes” to successfully deliver primary healthcare, especially in remote areas.

These are doctors trained in Ayurvedic medicine or homeopathy who learn skills for delivering a package of modern health care measures, based on a government protocol.

Even so, Kaur too said the lack of adequate healthcare workers remains a challenge in scaling up the initiative across India.

Government services only one part of the picture

However, initiatives such as the one in Paud have clear limitations – notably in who is targeted for services.

While the Indian government provides primary healthcare in rural areas and limited secondary and tertiary care in some cities, most healthcare services are provided by the private sector.

And here, chronic disease screening and prevention are typically paid for by the patient.

Only around 41% of Indian households have a member covered by health insurance. Most Indian health insurance schemes only cover hospitalization, excluding primary health care visits and tests which are critical to the prevention, screening, and early treatment for NCDs, including hypertension.

When people are finally diagnosed, it may often be at a later stage of the disease. In addition, treatment can involve hefty out-of-pocket costs for the average person.

Leelabai Jaigude, 60, is one such case in point.  A farmer, her hypertension medicine cost her Rs 80 ($1) every month at the private clinic that had diagnosed her, she said. But when she had to shell out Rs 550 ($6.60) for a blood test, she sought out a government center.

She was fortunate enough to live near the Rural Hospital, and now receives both her hypertension and diabetes medication there.

But not everyone is so fortunate to have a government facility near them. Overall, Indians bore more out-of-pocket expenditure than the government’s expenditure on health (48.2% compared to 40.6%), according to the Economic Survey 2022.

Alternative models proposed 

This has left experts such as Mohan looking for examples of how NCDs can be more effectively managed in private-sector healthcare and health insurance systems.

He points to the Kaiser Permanente network in the United States as one such model that has delivered good results in hypertension management.

Kaiser Permanente, which delivers healthcare to nearly 8.2 million Americans is a “Health Maintenance Organization” (HMO), which delivers holistic, cradle to grave care from primary to hospital level for those subscribed. The model operates nearly three dozen hospitals in the US. But since patients’ pay a subscription fee, HMOs have a vested interest in preventing disease from the outset – as it reduces their costs down the line.

In India however, no comparable private-sector models exist, Mohan laments – or at least not one beyond the isolated initiatives of individual practitioners or hospitals.

“The private sector is huge and very heterogeneous. And it’s very poorly regulated. So I am not aware of any concerted program or effort,” he said.

In addition, while the government system has a hierarchy ranging from the primary to the tertiary level, in the private sector, the continuum is not as clear. Private providers at primary care level typically operate separately from hospitals and specialists.

Finally, given that the private sector is largely unregulated, it also does not have to follow the government’s protocol for hypertension prevention detection and treatment.

“The government has a protocol. They [public sector] will follow this protocol, which is not the protocol that the private practitioners will follow. They will give their own medicines,” Narula said.

Kaur acknowledged this as a problem, saying that she and her team were very conscious of that fact in their work on the IHCI: “The strategies have to be different for the sectors. And since the public sector itself had not yet taken care of NCDs, trying to then replicate those strategies in private, we felt was a little premature,” she explained.

In the coming years as the WHO works towards expanding universal health coverage (UHC) in different regions, the public and private divide, which differs enormously across countries and regions,  will throw up a unique array of challenges depending on the setting.

Universal healthcare requires healthcare to reach a large number of people, address the issue of equity, and ensure the care covers a hybrid of diseases, said Kaur. “So I feel our work tried to address all the three,” she said, of the IHCI collaboration.

Additionally, this initiative taught the researchers what best practices work, like reducing the number of drugs to just a handful and procuring them in large quantities, and what the gaps are – the patient migration and ensuring continuity of care.

“Now, many states are using the same best practices for diabetes. And going forward, we’d like to do pilots, and see which of these best practices can be used for other NCDs as well,” Kaur said.

Image Credits: Disha Shetty, © 2021 Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation, Global Hypertension Report, WHO, Economic Survey 2022.