Extended day prescription refills for hypertension can be a game changer for health service delivery at the last mile

Top medical research institute Banaras Hindu University, senior government officials and public health leaders have said that policy measures like extended prescription for chronic diseases like hypertension helped India cope better with the chaos unleashed during the pandemic. At an event organized by FPAI, to release a policy brief and set of recommendations from Banaras Hindu University, health experts and senior representative of the government called for the need to focus on such nimble yet effective solutions to improve last mile delivery of health services.

In early 2020, soon after Covid struck, recognizing the need to safeguard India’s massive population group of ‘people living with NCDs’ (PLWNCDs), the Ministry of Health and Family Welfare, showed tremendous foresight by recommending a seemingly minor health system reform that could potentially save millions of those who are already suffering from chronic conditions like cardio vascular disease, diabetes or cancer. A guidance note from the MoHFW to all states issued on April 14th, 2020 advised that “all known diagnosed patients of hypertension, diabetes, chronic obstructive pulmonary disease and mental health to receive regular supply of medicines for up to 3 months through ASHAs or health sub-centres on prescription.”

Speaking at the event, Dr Sudarshan Mandal, Deputy Director General (NPCDCS), Dte GHS, Ministry of Health and Family Welfare, said “The government order calling for medicines to be available for chronic diseases in Primary Health Centres (PHCs) and Ayushman-Bharat Health and Wellness Centres (AB-HWC) was a timely measure that safeguarded many lives. It continues to be relevant and can be an important strategy to ensure that more and more people can keep their blood pressure properly treated and under control. While all NCDs require a continuum of care and treatment, it is critically important to focus on hypertension and diabetes mellitus, also called the silent epidemics of India. For the 22 crore hypertension patients, more than 8 crore diabetics and all the other suffering from NCDs in India, this can revolutionise health care delivery.”

Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University along with GRID Council under Project REACH-HTN, conducted an analysis across 4 states to gauge the success of making blood pressure medicine refills available for extended days as per the government guidance. Speaking at the release of this policy brief, Dr Sangeeta Kansal, Professor at the Department of Community Medicine, BHU and principal investigator of the project said, “Our analysis revealed that issuance of the government order recommending that medicines be made available for at least a month, has been overall beneficial for those relying of public health systems for their treatment – particularly those in rural India. It encouraged a number of innovations such as use of differentiated drug delivery system and disbursement of medicines through ASHAs and ANMs. The primary benefit was that it decentralised the process of drug delivery, bringing medicines closer to the people. IHCI districts were particularly efficient and structured in rolling out this government order.”

500 million Indians who rely on the public health system, particularly those with chronic health conditions have found it challenging to get a continuous supply of essential medicines. Taking time off from work every week to travel to the nearest primary health centre for a refill of their medication has been a huge barrier for patients to remain treatment compliant. Uncontrolled hypertension, considered to be the cause of maximum heart attacks in India, is most impacted by lack of treatment adherence. One in four adults have high blood pressure; among those only half have been diagnosed and of those, only one in ten have their blood pressure under control.

The recently released WHO guideline on hypertension treatment (2021), recommends that patients with stable blood pressure can be asked to visit clinics at 3-6 month intervals as an important strategy to improve hypertension control. Highlighting how ensuring treatment adherence has become a global priority, Ms Vandana Shah, Regional Director, Global Health Advocacy Initiative (GHAI) said, “Covid has put a spotlight on health systems across the world as they struggle to keep up with an unforeseen burden of care. Preparedness is the need of the hour. Making medicine refills available particularly in the remotest corners of the country is one such important solution. The policy brief issued by BHU has a number of important recommendations which can be implemented to further strengthen access to treatment such as a more streamlined and decentralised drug procurement system for the health and wellness centres (HWCs).”

BHU’s analysis showed that by December 2020 most states had provided hypertension medicines with relative success. Maharashtra was able to disburse extended days prescription for up to 90 days to almost 100% hypertensives registered with the NPCDCS program. Sufficient medicines were purchased in advance, sub centres used as a drug depot and HWCs rapidly scaled up. In Karnataka, the frontline health worker was asked to dispense medicines to hypertensive patients for one month at a time to avoid possible wastage. The study also noted that at least 40% of districts under the India Hypertension Control Initiative (IHCI) benefitted from a robust roll out of the order for extended days drug supply.

Noting the importance of streamlining hypertension treatment, Dr Basab Gupta, Additional Medical Superintendent, Kalavati Saran Hospital said “To make extended days refill a success, the first step is a standard treatment protocol, which is playing a major role in stemming the NCD crisis, as it successfully did with the HIV crisis.”

Speaking at the occasion, Dr Kalpana Apte, Secretary General, FPA India said, “Despite blood pressure medicines being safe, affordable and easily available, the control rates are dismal worldwide. Over 30% of the world population has hypertension and only 13.8% of cases are considered controlled. In India as well a large proportion of people diagnosed as hypertensive do not have their BP under control. This makes them extremely vulnerable to cardiac events and death. The guidance for extended days prescription, issued just when India was entering a hard lockdown nationwide, has immense potential of fixing the woes of last mile service delivery.”

Recommendations:

• To strengthen management, monitoring and treatment compliance for hypertension, develop criteria for patients who are eligible for extended prescriptions
• Build the capacity of healthcare workers for measurement of blood pressure and efficient management
• Leveraging telemedicine services and mobile based applications for patient monitoring and follow-up
• Strengthen the drug supply chain with efficient forecasting and stock procurement
• Decentralise drug procurement at local (district) and state levels
• Simplify the anti-hypertensive drug list by limiting the number of categories and drug molecules prescribed
• Rationalize indenting and budget allocation practices as per local burden and coverage targets

MB Bureau