Cardiovascular diseases (CVD) are the leading cause of death among adults in India. One of the major drivers of heart attack and stroke is untreated high blood pressure or hypertension. Hypertension is a silent killer as most patients do not have any symptoms.
India has more than 200 million people with hypertension, and only 14.5% of individuals with hypertension are on treatment. Unlike many other diseases, hypertension is easy to diagnose and can be treated with low-cost generic drugs.
India Hypertension Control Initiative (IHCI) is a multi-partner initiative involving the Indian Council of Medical Research, WHO-India, Ministry of Health and Family Welfare, and State governments to improve blood pressure control for people with hypertension. The project initiated in 26 districts in 2018 has expanded to more than 100 districts by 2022. More than two million patients were started on treatment and tracked to see whether they achieved BP control.
The project demonstrated that blood pressure treatment and control are feasible in primary care settings in diverse health systems across various States in India. Before IHCI, many patients travelled to higher-level facilities such as community health centres (block level) or district hospitals in the public sector for hypertension treatment. Over three years, all levels of health staff at the primary health centres and health wellness centres were trained to provide treatment and follow-up services for hypertension.
Five scalable strategies
Nearly half (47%) of the patients under care achieved blood pressure control. The BP control among people enrolled in treatment was 48% at primary health centres and 55% at the health wellness centres. The most encouraging finding was that BP control in the primary care facilities was higher when compared with hospitals. The availability of medications in the peripheral facilities made it easier for the patient to continue treatment, thus improving BP control.
The project was built on five scalable strategies: First, a simple treatment protocol with three drugs was selected in consultation with the experts and non-communicable disease programme managers. Second, the supply chain was strengthened to ensure the availability of adequate antihypertensive drugs. Third, patient-centric approaches were followed, such as refills for at least 30 days and assigning the patients to the closest primary health centre or health wellness centre to make follow-up easier. Fourth, the focus was on building capacity of all health staff and sharing tasks such as BP measurement, documentation, and follow-up. Finally, there was minimal documentation using either paper-based or digital tools to track follow-up and BP control.
Data-driven approach
One of the unique contributions of the project was a data-driven approach to improving care and overall programme management. The list of people who did not return for treatment was generated through a digital system or on paper by the nurse/health workers. Patients were reminded either over the phone or by home visit (if feasible). This strategy motivated a large number of patients to continue treatment. In addition, programme managers reviewed aggregate data at the district and State levels to assess the performance of facilities in terms of follow-up and BP control.
Scaling hypertension treatment is feasible given the enablers in India’s health system. When procured at scale, the generic antihypertensive drugs cost only ₹200 per patient per year.
India has a vast network of primary health centres where doctors and nurses can be trained to diagnose and treat hypertension.
Health wellness centres under Ayushman Bharat Yojna have specially trained nurses who can measure blood pressure and provide refills for patients initiated on treatment by doctors at the higher health facility.
In addition, E-Sanjeevani, a telemedicine initiative, facilitates teleconsultations.
Making progress
Since 2018, the project team has worked hand-in-hand with State health departments to strengthen the hypertension component within the framework of ongoing initiatives for the control of noncommunicable diseases. Based on the positive experience, several States have already started implementing the strategies beyond project districts.
We need to address a few challenges to reduce the treatment gap. Many people with hypertension are not aware of their high BP. All health facilities can measure BP at the entry point for people who visit the doctor for any health problem. This strategy, also known as opportunistic screening, does not require additional resources.
The availability of good quality blood pressure monitors is a prerequisite for accurate BP measurement. Extended refills up to 60 days can reduce visits to health facilities.
One of the challenges is the involvement of the private sector, where a large number of people with hypertension currently seek care. We must overcome the challenges to ensure early detection and treatment of hypertension to reduce preventable deaths and disability due to heart attack, stroke, and chronic kidney disease.
(Prabhdeep Kaur is Senior Scientist and Head of Division of NCD, ICMR-National Institute of Epidemiology, Chennai, and is a member of the IHCI team. kprabhdeep@nieicmr.org.in)
- Cardiovascular diseases (CVD) are the leading cause of death among adults in India
- India has more than 200 million people with hypertension, and only 14.5% of individuals with hypertension are on treatment
- Unlike many other diseases, hypertension is easy to diagnose and can be treated with low-cost generic drugs
