At the height of the COVID-19 pandemic, from January 2020 through June 2021, health and wellness centers in Punjab, India, trained over 2,600 health workers and provided more than 5.2 million consultations with patients, including 2.5 million consultations on diabetes and hypertension.
India’s population suffers from high rates of hypertension, which is a key risk factor for cardiovascular events and deaths. More than 200 million adults in India have hypertension, or abnormally high blood pressure, and only 20 million have it under control. Only half of people with high blood pressure have been diagnosed, and only 10% of patients with a diagnosis have successfully lowered their blood pressure, according to a recent study by the Indian Council of Medical Research (ICMR), a leading research organization. Making screening and treatment available at the primary healthcare level is considered the most effective way to curb this growing public health crisis, often called the silent epidemic of India. The country’s highest hypertension burden is in the state of Punjab, with a prevalence rate estimated to be as high as 35.7%.
Access to health services is often most difficult for people in remote, rural areas. This is known as the “last mile” problem because the last mile of services can be the hardest to deliver. Reaching underserved, vulnerable populations is not just a resource challenge—it is a challenge of political will, logistics and planning.
To address this problem in India, Resolve to Save Lives (RTSL) tapped the Global Health Advocacy Incubator (GHAI) in 2019 to pilot an innovative, multistakeholder partnership to prioritize hypertension treatment as part of a broader effort to strengthen the country’s primary healthcare system. Applying GHAI’s experience in changing health policies, the project supported civil society engagement with policymakers. RTSL was part of the India Hypertension Control Initiative, along with the Government of India, the World Health Organization and ICMR.
GHAI partnered with the state government of Punjab and the Postgraduate Institute of Medical Education and Research (PGIMER), a government-designated “center of excellence” in medical science, to launch the Punjab Hypertension Project. The initiative was designed to test and deploy innovations to remove barriers to hypertension treatment with the goal of making services available to all. The project focused on three priorities: increasing utilization of hypertension control and treatment, improving drug procurement and delivery systems and increasing budget allocations.
Increased utilization of hypertension control and treatment
When it launched in 2018, India’s Ayushman Bharat (universal healthcare) initiative called for the creation of health and wellness centers (HWCs) to provide comprehensive primary healthcare, including free essential drugs and diagnostic services, close to people’s homes. The COVID pandemic threatened these plans. GHAI worked with PGIMER to support the Punjab state government in the planning and expansion of HWCs, despite the COVID lockdown. This included strategies to train human resources personnel and provide technical and capacity-building support for telemedicine services, including the adoption of a “hub and spoke” model to connect patients with healthcare workers in different locations. GHAI provided technical assistance and logistics support for internet connectivity at HWCs to enhance service delivery, patient feedback systems and health monitoring and evaluation. GHAI also conducted online capacity-strengthening programs for community health officers. These efforts enabled patients to receive hypertension diagnoses and treatments, even during the government’s COVID lockdown.
With the project’s support, the number of HWCs in Punjab grew more than fourfold from October 2019 to March 2022, reaching a total of 2,800 centers. In addition, over 2,600 community health officers and district program managers were trained to provide care.
Improved drug procurement and delivery systems
To reduce the likelihood of medicine blackouts at HWCs, GHAI worked with the state government to ensure seamless procurement and availability of blood pressure medicines. The essential medicines list was expanded to include three hypertension protocol drugs: Amlodipine, Telmisartan and Chlorthalidone. Punjab became the first state in the country to adopt a drug logistics model for the HWCs, an accomplishment that was announced by the state’s health minister. A dedicated van makes medicine deliveries to each HWC as needed, reducing the lag time for drug deliveries from 45 days to less than 7 days.
Budget advocacy for better coverage Improved drug procurement and delivery systems of treatment services
GHAI provided technical support to Punjab’s Department of Health to outline its workplan and budget needs in its applications for central government funds, resulting in an increase of Punjab’s budget for hypertension control to US$3 million.
Strengthening political will and creating a strong narrative
While the technical and institutional improvements in Punjab were necessary, it took political will and public support to implement and sustain them. GHAI, the state government and PGIMER conducted a media campaign to complement their ongoing engagement with state policymakers. The enlistment and training of cardiologists and public health experts to disseminate their knowledge in ways the public could understand was key to the campaign’s success. The partners held workshops to provide journalists with evidence and context for the hypertension burden in India, and they hosted events on key dates, including World Hypertension Day and Diwali. Ultimately, hundreds of articles were published, a quarterly newsletter was distributed to policy influencers and hypertension became a trending topic on social media. The campaign also enhanced public awareness through community outreach stations that provided free blood pressure readings, screenings and encouragement for at-risk individuals to seek treatment.
The collaboration between GHAI, the state of Punjab and PGIMER made it possible to expand access to primary healthcare services, even during a pandemic. Over the course of the project, Punjab expanded telemedicine services to over 1,600 HWCs across the state. From January 2020 through September 2021, HWCs conducted more than 5.5 million consultations with patients, including 2.7 million consultations on diabetes and hypertension.
India’s national government ranked Punjab the top state for HWC implementation, a recognition that has prompted other states to replicate Punjab’s success. In March 2022, GHAI partnered with India’s premier medical institution, All India Institute of Medical Sciences (AIIMS), to expand the hypertension support model in four additional states.
- Political will and public awareness are key to building support for health system strengthening and budget advocacy
- Civil society organizations (CSOs) play a key role in helping governments identify healthcare bottlenecks and proposing innovative solutions to improve health services delivery
- Medical, research and academic institutions can play a critical role in developing solutions to healthcare challenges; their evidence should be used to shape policy change prioritization, planning and campaigns
- Ongoing operational research can help guide crucial mid-course corrections to healthcare programs
- Advocacy doesn’t end when programs are funded. Making sure public funding reaches the people it’s meant to benefit is key to sustaining allocations in future budget cycles.