Hypertension, a non-communicable disease (NCD), rightly termed as a ‘silent killer’, is a leading cause of serious health conditions like kidney disease, heart disease and stroke, when left untreated. A recent WHO report reveals that, globally, hypertension affects one in three adults approximately, and 4 out of every 5 people with hypertension are not adequately treated. The report further states that a better health care system can save around 76 million people from dying between 2023 and 2050.
In India, over 220 million people suffer from hypertension and only about 12% of people have their blood pressure under control. As a response to these numbers, on World Hypertension Day 2023, the Union Health Ministry unveiled the “75/25” project for the standardisation of care for 75 million people with diabetes and hypertension by the year 2025. The Outcome Budget document of the Union Budget 2023-2024 for the first time introduced hypertension and diabetes treatment as outcome indicators.
Meanwhile, in Tamil Nadu, a survey conducted by the Tamil Nadu Health Systems Reforms Project in 2020, using the WHO’s STEP-wise approach to NCD risk factor surveillance, put the prevalence of hypertension among the adult population of Tamil Nadu at 33.9%.
Medical outreach in Tamil Nadu
In an effort to take hypertension care across the last mile and into people’s homes, the Tamil Nadu government launched the Makkalai Thedi Maruthuvam (MTM) scheme in 2021. The scheme aims to improve early screening of hypertension, improve accessibility to health care services and reduce out-of-pocket expenditure for patients. Home-based screening, and drug delivery at the doorstep of beneficiaries are two of the important tasks undertaken by the women health volunteers under the scheme. As per the recent data released by the Directorate of Public Health and Preventive Medicine, 55.1 lakh new cases of hypertension and 26.15 lakh cases of diabetes and hypertension have been diagnosed over the last two years.
The core principles of the MTM scheme were borne out by research published by the Lancet in December 2022 titled “Hypertension treatment capacity in India by increased workforce, greater task-sharing and extended prescription period: a modelling study”. The study identified seven cadres of medical staff as potentially playing roles in hypertension care: physicians, mid-level health providers (MLHP), nurses, auxiliary nurse midwives (ANM), accredited social health workers (ASHA), multipurpose workers (MPW) and clerical staff. The study analysed that if the diagnosis and treatment of hypertension were left to the remit of physicians, working with the available task force of physicians, only an estimated 8% of the 245 million adults with hypertension can be treated. It, therefore, recommends task sharing - ie, using the other cadres of health professionals with adequate training and under robust supervision in hypertension healthcare. In a practical application of the principle of task sharing, the MTM recruited a 20,000-strong workforce of local women, training them to screen for hypertension. Identified patients are then referred to higher centres for diagnostic testing and treatment. The treatment then follows a three-month medication protocol, also recommended by the study. Following these twin principles of task sharing and extended prescription period, as of July 2023, 1,00,55,524 individuals have been screened, with 60 lakh hypertensive patients receiving treatment under the scheme.
Analysis of how MTM works
The true success of the scheme can be estimated only if data from the ground is rigorously and objectively analysed over the coming years. In these circumstances, and in an attempt to record the voices of hypertensive patients taking treatment at the Primary Health Centres (PHC), in Tamil Nadu, researchers from Citizen Consumer and Civic Action Group (CAG), met with a few patients, most of them being women and daily wagers, in Tiruvannamalai district.
Most of them had symptoms of fatigue, giddiness and headache when they were diagnosed to be hypertensive. The PHCs were located at a distance of 2-3 km from their homes. The MTM volunteer for the area, who often lived in the vicinity, would deliver the medicines on time to ensure that the medicines were taken regularly. Since most of the patients were daily wagers working under the government’s 100 days wages - MGNREGA scheme, the woman volunteer would also visit them at the work site to hand over the medicines. Blood pressure was also checked periodically to ensure it was under control. If it was not, the volunteer advised them to consult the doctor immediately. There were also phone calls to remind them about their future consultations at the PHCs. The patients were highly appreciative of the services. Unless there were other complications like heart or kidney ailment, medicines were prescribed for 3 months at PHCs.
Some concerns emerge
There were a few concerns as well that were brought to the notice of the researchers. A recurring theme was that the PHCs allotted a particular day in a week for NCD related doctor consultation. Unless it was an emergency, they were expected to visit the PHC for their regular checkups only on the prescribed day, in the mornings. This resulted in long waiting hours at the PHCs and their working day was affected with loss of one day’s wage. The occasional non-availability of the doctor on that particular day, added to their woes. The patients felt that it would be good if doctors were available on all days and preferably in the evenings, so that they didn’t have to lose a day’s salary. This points to a practical problem that even while attempting task sharing, the limited number of available physicians still creates a bottleneck in the system.
Hamsaveni, a 55-year-old hypertensive patient, told us that different medicines were given each time. This raises the question of sufficient supply of hypertensive drugs. The extended prescription protocol especially stresses drug availability. This needs to be addressed through actual investment into drug stock, along with accurate forecasting, strong procurement and distributions systems and good stock taking tools to ensure an uninterrupted drug supply.
It was noted that the MTM’s women health volunteers were paid less than Rs. 5000 per month. Apart from the wage itself being low, the health volunteers also commented on the targets they were set, and being incentivised for meeting the targets. In the health sector, it is generally understood that a system of targets and incentives could potentially lead to wrongful acts. This system of working therefore needs to be monitored carefully, and thoroughly analysed for safety and precautionary measures set in place. This is especially important as the scheme itself is used by vulnerable groups of people whose voices could easily be missed.
The original study in fact stresses that for success, it is important to select and continuously train health workers and offer them suitable supervision, to support them with reliable patient tracking data systems and consistent medication supplies and to compensate them adequately in proportion to their roles.
Currently, data coming out of the MTM scheme only indicates the number of individuals who have been assessed as hypertensive and receiving treatment under the scheme. The true measure of success though would be the number of individuals whose hypertension has been controlled effectively. The government needs to actively access and assess these numbers. Another important question is whether the scheme is truly sensitive to the needs of the most vulnerable demographic. A more thorough framing of the problem of access to NCD screening and treatment services in the community is necessary to assess whether the needs of these groups are being met. While the MTM definitely allows for better coverage of NCD services, whether it covers the needs of those with disabilities, mental health issues, or all persons from the tribal communities needs to be measured.
Tamil Nadu’s initiatives fall closely in line with aiming for universal health coverage, but the important issues highlighted above need to be looked into and acted upon, as this will go a long way in reducing the NCD burden on the state.
This article was originally published by The Hindu on 05 January 2024.