The past decade has seen the emergence of cardiovascular diseases as the leading cause of mortality in India both in urban and rural areas. Undetected and uncontrolled hypertension is a major underlying reason for this. Although relatively easy to detect and manage, raised blood pressure is now a full-fledged public health crisis with almost a quarter of Indian adults (with regional variations) suffering from this condition according to National Family Health Survey-5 (NFHS-5) estimates. The problem is more aggravated with people aged 45 years and beyond.

As per the Longitudinal Aging Study in India data, of every 100 persons aged 45 years and beyond, 45 have hypertension — only 25 of which have received a diagnosis and, of which, only 15 have their blood pressure under control! Inconsistent access to anti-hypertensive medicines often leads to treatment non-adherence and default. If patients with hypertension have a consistent supply of medicines and with adequate monitoring, there is a possibility that their blood pressure is maintained within safety limits and adverse outcomes are averted.

This will also reduce the number of visits they would then make to the health facilities, and thus the load on the already overloaded health facilities would likely decrease, while reducing the out-of-pocket expenditure for the care seekers. Global evidence suggests that once target blood pressure is reached, patients can be asked to visit clinics at three to six month intervals; multi-month prescription refills could be a possible way forward.

An innovation

The Government of India, at the beginning of 2019, set a target for a 25 per cent reduction in high blood pressure by 2025. In early March 2020, the Ministry of Health and Family Welfare wrote to all States and Union Territories (UTs) recommending to make anti-hypertension drugs available for free and in sufficient quantities at all Ayushman Bharat – Health and Wellness Centres (ABHWCs), at Sub-centre and Primary Health Centres (PHCs) as part of an expanded package of comprehensive service delivery and Free Drug Service Initiative (FDSI).

Later, as the Covid-19 pandemic hit, the Ministry of Health and Family Welfare released a guidance note to all States on April 14, 2020, advising all known diagnosed patients of hypertension, diabetes, chronic obstructive pulmonary disease and mental health to receive a regular supply of medicines for up to 90 days through ASHAs or health sub-centres on prescription.

The ‘extended refill prescription’ approach for chronic diseases was an innovation (or rather an ‘experiment’) that was attempted through India’s massive yet variegated public health system at a moment when it was challenged maximally by a raging pandemic. Whether the advisory was feasible or not for implementation was, however, debatable. Previous Common Review Missions had noted that the health system across States in India had varied capacity to disburse extended refills.

We conducted an analysis across States in India between November 2020 and February 2021 to gauge the success of making blood pressure medicine refills available for extended days as per the government guidance. We examined the experiences gathered by programme managers in the process. Our methods were exploratory and included deploying a range of secondary data collation approaches.

Our exploratory analysis revealed that by December 2020, at least some States could provide hypertension medicines for about a month in at least some of the districts depending on the stocks available with them initially. Some could disburse the medicines even for further extended durations and follow through with subsequent rounds of disbursement. Operationalisation was limited to rural areas mostly (urban areas mostly not covered). Several models had emerged in the process regarding procurement, storage and differentiated delivery. The Health and Wellness Centres had emerged as drug depots and delivery kiosks.

The frontline workers provided the last mile house-to-house connectivity with the community. At times, mobile vans were used for improved penetration to far-flung areas. Virtual technology provided leverage for staff training and monitoring. Districts where the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) and/or the India Hypertension Control Initiative (an ICMR-WHO collaborative) were active, also witnessed efficient drug distribution and high blood pressure control among patients.

Delivery models

It was noted that the decentralised process of drug delivery had brought healthcare closer to the patient, and was anecdotally more cost efficient for the patients. This was feasible despite the movement restrictions imposed by the pandemic. Differentiated service delivery models were also workable and there was a need to further study these for contextual learnings. These decongested the health facilities and made stock indenting easier.

We, however, noted that to be able to be on the safer side of things, there is a need to ensure that the patients were on stable drug prescription (i.e., their blood pressure is fairly stable with the drugs they were already taking and hence, it was unlikely that their prescription would change over the extended duration for which the refill was provided), and that blood pressure monitoring was strong enough. Thus, the frontline service providers and, if possible, even the patient/family member should know how to measure and monitor blood pressure at outreach/home.

We recommend that the practice of disbursing extended refills to patients with hypertension through the public health system be considered, going forward. There is a need to assess this innovation in a more scientific manner.

Mohapatra is Executive Director, GRID Council, NOIDA. Kansal is Professor, Institute of Medical Sciences, BHU, Varanasi

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