Improving access to medicines led to better hypertension control

In a recently released “Global report on hypertension 2025”, the World Health Organization (WHO) lauded India’s effort to control hypertension. It has appreciated the country’s multi-pronged strategy for improving access to hypertension medicines. The WHO’s report states that India’s approach has yielded substantial public health gains and improved blood pressure control rates. Realizing the adverse impact of uncontrolled hypertension, India had launched ‘Indian Hypertension Control Initiative (IHCI) in November 2017. This is a 5-year initiative involving the Ministry of Health & Family Welfare, Indian Council of Medical Research, State Governments, and WHO-India to achieve 25 per cent relative reduction in raised blood pressure. In the middle of the target period the flagship initiative, IHCI won the ‘2022 UN Interagency Task Force, and WHO Special Programme on Primary Health Care Award’ at the UN General Assembly side event held on 21st September 2022 at New York.

Hypertension, commonly known as high blood pressure, is one of the serious growing public health issues in India. High blood pressure (BP) is the leading risk factor for cardio vascular diseases among Indian adults. Hypertension diagnosis is established if the systolic blood pressure is =140 mmHg and/or diastolic blood pressure is =90 mmHg, on two different days. The blood pressure control rate was minimal prior to implementation of IHCI. It is estimated that 25 per cent of adults in India has high blood pressure but only 14 per cent of high blood pressure adult patients could achieve blood pressure control. Uncontrolled high blood pressure is responsible for heart attacks and strokes. The successful treatment of high blood pressure is helpful preventing fatal heart attacks and strokes; Reducing disability, by preventing non-fatal heart attacks and strokes, and preventing dialysis; Reducing medical costs spent on caring for patients who are having heart attacks and strokes, and for the rehabilitation and nursing care needed in the aftermath of a stroke or heart attack; and Improving productivity by reducing the number of people who are disabled by CVDs and are unable to work and who may require long-term nursing care. IHCI was implemented in identified districts of Punjab, Madhya Pradesh, Kerala, Telangana, Maharashtra, West Bengal, Chhattisgarh, Karnataka, Andhra Pradesh, Sikkim, Goa, Bihar, Rajasthan, Jharkhand, Tamil Nadu, Uttar Pradesh, Puducherry, Nagaland, and Gujarat. The IHCI programme is complementary to the National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke (NPCDCS) of the Ministry of Health & Family Welfare, Government of India. India voluntarily fixed the target of reducing the prevalence of high blood pressure by 25 per cent by 2025. Improving access to medicines is not the only reason for success of IHCI, it is the success of combined strategies employed. Other strategies include standard treatment protocol for hypertension, decentralised care closer to patients’ home, strengthening information system, etc.  

Improving access to medicines too has multiple strategies
Economic barrier is addressed: There have been a mechanism for price control of medicines. The Drugs Price Control Order implemented by the Department of Pharmaceuticals ensures that price of essential medicines does not go beyond the reach of common masses. There is an Authority Called National Pharmaceutical Pricing Authority not only fixes the prices of medicines listed in NLEM but also take measures to promote accessibility.

The prices of National List of Essential Medicines (NLEM) are monitored and ceiling prices are fixed. No company can charge more than ceiling price. It is a market-based mechanism, not manufacturing cost basis. It is just to keep a balance between the price at which the manufacturers intend and the affordability.

Availability of medicines improved in government healthcare facilities: The National government has initiated free drug services in government hospitals. Under the National Health Mission (NHM), the Free Drugs Service Initiative (FDSI) was launched in 2015. The new programme was launched with looking at past experience at state level as health care falls within states’ domain. Prior to this the free drugs were available based on different programmes like Janani Shishu Suraksha Karyakaram (JSSK). The programme, FDSI aimed at ensuring universality of access to free and quality medicines, irrespective of socioeconomic status.

Medicines constitute a substantial portion of out of pocket (OOP) expenditure for health care. This issue hinders many from taking full treatment leading to unsatisfactory outcome. Besides, high OOP leads to catastrophic situation in poor. The beauty of the programme is seamless transformation at state level by streamlining the existing process and establishing new systems. The previously identified bottle necks like procurement issues, poor supply chain, poor management of information system, poor storage practices. The operation guidelines ensure the technical as well financial support to state governments to strengthen their supply chain system. IT enabled information system gives the real time availability of medicines. Much of the supply system issues are avoided. The free uninterrupted availability of medicines as required by Standard Treatment Guideline (STG) further boosts the image of public health facilities improving the footfalls.

Availability of medicines at affordable cost improved
The government has been promoting generic medicines though specially opened generic medical store. These medicine stores are operating under ‘Pradhan Mantri Bhartiya Janaaushadhi Pariyojana (PMBJP)’ providing quality medicines at affordable price. There are more than 14000 Jan Aushadhi Kendras (JAKs) across the country providing different categories of medicines including ant-hypertensive medicines. The scheme is successful improving access to quality medicines   at affordable price. It is also successful in changing perception that the generic medicines are of poor quality as they are cheaper. The prices of Jan Aushadhi Medicines are cheaper at least by 50 per cent and in some cases, by 80 per cent to 90 per cent of the market price of the branded medicines. Similarly, there are schemes operating at state level: There is Chief Minister’s Pharmacy in Tamil Nadu. The generic medicines at CM’s Pharmacies are roughly 30 per cent cheaper than those at Jan Aushadhi outlets. The availability of generic quality medicines at a cost much cheaper than branded (branded generics) helps people especially requiring medicines for chronic conditions. 

Access to medicine improves therapeutic care as medicines are fundamental requirements in therapeutics. This is logic but there are few examples which have proved this logic. The successful hypertension control is achieved through the multiple strategies adopted in India: generic drug promotion, free drug supply and effective price control   mechanism. All the three strategies have improved access to medicines and have got the World Health Organization’s attention. This is a classic example of India’s success story of implementation of pharmaceutical public health. The terminology of pharmaceutical public health is not common in India.