Krishna, a 43-year-old from Telangana, experienced palpitations and uneasiness. He thought it was a part of aging, but on a routine visit to the local RMP he learned his blood pressure was dangerously high. Like Krishna, most healthcare seekers reach out to private providers first, especially in rural India. Yet millions remain unaware of their hypertension, the leading cause of cardiovascular diseases which are responsible for nearly one-third of deaths globally (1). Despite the efforts of the UN awarded Indian Hypertension Control Initiative (IHCI), ICMR affirms that we’re unlikely to meet the 25 by 2025 goal for reducing hypertension (2).
The 25 by 25 goal launched by World Heart Federation and incorporated in the WHO NCDs Global Action Plan, aims to reduce premature deaths due to non- communicable diseases, including cardiovascular diseases, by 25 per cent by 2025 (3). India was the first country to adopt a National Action Plan in response to this, with Indian Hypertension Control Initiative (IHCI) being a pivotal part (4). While the integrated approach under IHCI has shown promising results, hypertension remains the most common risk factor for CVDs in India, accounting for over 220 million cases out of which merely 12 per cent have it under control (5).
Despite the urgent need, access to care remains limited. Many patients in healthcare-deprived regions rely on private providers who often lack training and resources to provide quality care. Even though the private sector caters to majority of India’s outpatient care, a recent ISB study conducted in rural and peri-urban Telangana identified crucial gaps in adherence to screening, monitoring and follow-up protocols among private sector providers (6). This poses a significant challenge in a milieu where private providers are the first point of contact for most patients, underscoring the need for better integration of private providers into the national healthcare goals.
Can lessons be drawn from PPSA model for TB control?
In the case of Tuberculosis control in India too, the need for public-private collaboration to improve early detection and diagnosis was evident as private sector caters to most of the first-time care seekers, managing over 70 per cent of TB cases. To this effect, what started as a modest pilot in three districts got scaled up by national TB program into Patient Provider support agencies (PPSA) model, now active in 203 districts across 23 states in India (16). PPSAs play a key role by engaging private providers for end-to-end TB care services.
Insights from innovative models such as PPSAs, especially pertaining to their financial viability, cost effectiveness (8) and their impact on disease burden (7), can be extrapolated to engage the private sector in hypertension management nationally. Public Private Partnerships (PPPs) could play a transformative role in bridging hypertension care gaps by fostering the integration of private sector capabilities into health systems, making healthcare accessible for all (9).
What can PPPs do for hypertension management?
Public Private Partnerships can address hypertension crisis in India by pooling expertise and resources across sectors. For instance, private sector can support IHCI by mobilising private clinics, pharmacies and even popular community hotspots to become screening hubs, making hypertension screening a norm rather than an exception. The effectiveness of this model is evidenced by Bihar Pharmacist Hypertension Study (10) and USA’s Barbershop model.(11) Private partners can ensure affordable access to antihypertensive medications through bulk procurements or subsidies. Moreover, they can lead training and capacity building programs to ensure standardised care that conforms to IHCI protocols.
Since private sector is the first point of contact for majority in India, PPPs can be instrumental in enhancing healthcare access, easing the burden of navigating a complex healthcare system on the patients. Leveraging private sector capabilities in data analytics and technology, these partnerships can enable large scale implementation of digital health solutions via IHCI’s Simple app.
Likewise, the public sector must demonstrate flexibility by streamlining regulations, adopting innovative outcome-based financing models, ensuring transparency and equal participation in joint decision making. Learnings from successful PPP models such as Kenya’s Healthy Heart Africa (12) can be a valuable resource.
Striking the right balance
The World Economic Forum attests to the impact PPPs can have on the prevalence of quality healthcare in India, especially in underserved regions. Through interventions such as aiding the availability of private experts in public settings, technological innovation and optimal utilisation of infrastructure and resources, PPPs can affect sustainable long-term improvements in health systems.(13) Some of the key areas to ensure the success of PPPs are identifying the right opportunities for investment, having a strategic plan for healthcare modernisation, institutional checks and balances to ensure accountability and minimise fiscal risks. (14)
The WHO has devised a decision-making tool to guide and support Member States in analysing critical elements for decision- making when considering collaboration with private sector entities or where governments are required to engage with industry in the policy process for measures designed to prevent and control NCDs. (15) Policy refinements across India’s hypertensive care spectrum in the advent of public-private partnerships will be crucial to reach the goals in time and safeguard public interest. WHOs comprehensive tool will empower policy decisions regarding PPPs that are profitable, effective and sustainable.
Conclusion
Controlling hypertension in India calls for a comprehensive approach that integrates private sector’s expertise, technology and innovation. While India’s IHCI has made remarkable difference through public health infrastructure, public-private collaborations offer opportunities to amplify this progress. By forming robust public private partnerships focused on accessibility, affordability and quality of care, India can strengthen its hypertension management framework.
As the global health stakeholders prepare for the 2025 UN General Assembly’s Fourth High Level Meeting on NCDs, India’s public and private health stakeholders must come together to formalise public-private collaborations that prioritise equitable access to hypertension care.
References:
- World Health Organization: WHO. (2019, June 11). Cardiovascular diseases. https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_1
- Seema Prasad. (2024, March 10). India won’t meet UN targets to reduce premature mortality from major non-communicable diseases: ICMR-NCDIR. Down to Earth. https://www.downtoearth.org.in/health/india-won-t-meet-un-targets-to-reduce-premature-mortality-from-major-non-communicable-diseases-icmr-ncdir-92475#:~:text=NCDs%20account%20for%2066%20per,NCD%20monitoring%20framework%20in%202013.
- Vervoort, D. (2019). Evaluating the World Heart Federation’s 25 by 25: The Forgotten Millions. Global Heart, 14(4), 401. https://doi.org/10.1016/j.gheart.2019.08.004
- National Multisectoral Action Plan for Prevention and Control of Common NCDS (2017-2022). (2017). In National Multisectoral Action Plan for Prevention and Control of Common NCDs (2017-2022) [Report]. https://main.mohfw.gov.in/sites/default/files/National%20Multisectoral%20Action%20Plan%20%28NMAP%29%20for%20Prevention%20and%20Control%20of%20Common%20NCDs%20%282017-22%29_1.pdf
- World Health Organization: WHO. (2020, September 16). Hypertension. https://www.who.int/india/health-topics/hypertension#:~:text=India%20Hypertension%20Control%20Initiative(IHCI)&text=Uncontrolled%20blood%20pressure%20is%20one,and%20are%20being%20followed%20up.
- Gupte, S. S., Sachdeva, A., Kabra, A., Singh, B. P., Krishna, A., Pathni, A. K., Sharma, B., Moran, A., Mamindla, A. R., Kannuri, N. K., & Deo, S. (2024b). Private provider practices and incentives for hypertension management in rural and peri-urban Telangana, India– a qualitative study. BMC Health Services Research, 24(1). https://doi.org/10.1186/s12913-024-11560-5
- Arinaminpathy, N., Deo, S., Singh, S., Khaparde, S., Rao, R., Vadera, B., Kulshrestha, N., Gupta, D., Rade, K., Nair, S. A., & Dewan, P. (2019). Modelling the impact of effective private provider engagement on tuberculosis control in urban India. Scientific Reports, 9(1). https://doi.org/10.1038/s41598-019-39799-7
- Deo, S., Jindal, P., Gupta, D., Khaparde, S., Rade, K., Sachdeva, K. S., Vadera, B., Shah, D., Patel, K., Dave, P., Chopra, R., Jha, N., Papineni, S., Vijayan, S., & Dewan, P. (2019). What would it cost to scale-up private sector engagement efforts for tuberculosis care? Evidence from three pilot programs in India. PLoS ONE, 14(6), e0214928. https://doi.org/10.1371/journal.pone.0214928
- PricewaterhouseCoopers. (n.d.-b). PPPs in healthcare: Models, lessons and trends for the future. PwC. https://www.pwc.com/gx/en/industries/healthcare/publications/trends-for-the-future.html
- Das, H., Sachdeva, A., Kumar, H., Krishna, A., Moran, A. E., Pathni, A. K., Sharma, B., Singh, B. P., Ranjan, M., & Deo, S. (2023). Outcomes of a hypertension care program based on task-sharing with private pharmacies: a retrospective study from two blocks in rural India. Journal of Human Hypertension, 37(11), 1033–1039. https://doi.org/10.1038/s41371-023-00837-7
- Victor, R. G., Lynch, K., Li, N., Blyler, C., Muhammad, E., Handler, J., Brettler, J., Rashid, M., Hsu, B., Foxx-Drew, D., Moy, N., Reid, A. E., & Elashoff, R. M. (2018). A Cluster-Randomized trial of Blood-Pressure reduction in Black barbershops. New England Journal of Medicine, 378(14), 1291–1301. https://doi.org/10.1056/nejmoa1717250
- Ogola, E. N., Okello, F. O., Herr, J. L., Macgregor-Skinner, E., Mulvaney, A., & Yonga, G. (2019). Healthy Heart Africa—Kenya: A 12-Month Prospective Evaluation of Program impact on health care providers’ knowledge and treatment of Hypertension. Global Heart, 14(1), 61. https://doi.org/10.1016/j.gheart.2019.02.002
- Public-private partnerships can benefit healthcare in India. (2024b, September 10). World Economic Forum. https://www.weforum.org/stories/2022/09/public-private-partnerships-india-healthcare-ecosystem/
- World Health Organization: WHO. (2023, January 26). New WHO report lays out concrete actions for governments to optimize public–private partnerships for health. https://www.who.int/europe/news/item/26-01-2023-new-who-report-lays-out-concrete-actions-for-governments-to-optimize-public-private-partnerships-for-health
- NCDs, G. C. M. S. F. (2024, July 14). Supporting member states in reaching informed decision-making on engaging with private sector entities for the prevention and control of noncommunicable diseases: a practical tool. https://www.who.int/publications/i/item/9789240094840
- Tuberculosis elimination in India: What’s next for private-sector engagement? (n.d.). PATH. https://www.path.org/our-impact/articles/tb-elimination-in-india-whats-next-for-private-sector-engagement/#:~:text=PPSA%20is%20working%20but%20there’s,a%20challenge%20of%20the%20past