Hypertension is a leading risk factor for mortality in India with more than 200 million people in the country estimated to have high blood pressure (BP). There is, however, very little awareness about this silent killer with 75% of the rural and 60% of the urban Indian population unaware of their hypertensive status. BP control in these patients is worse, 90% of the rural and 80% of the urban Indian population have a BP above recommended target values. This needs to be addressed by providing urgent attention towards provision of access to diagnosis, management and monitoring of hypertension at the primary care level. For clinical guidance on this issue, the Ministry of Health and Family Welfare, India recently published the standard treatment guideline on screening, diagnosis, assessment, and management of primary hypertension in adults in India. This guideline balances the best available evidence with what is operationally feasible and affordable in the context of the Indian public health system, by using a pragmatic adaptation methodology, which was recently published in the BMJ.

Steps towards improvement

The State Government of Kerala, with technical assistance from iDSI, is now planning to implement quality standards which are measurable prioritised recommendations from this guideline. It aims to increase identification of new cases of hypertension by providing opportunistic BP measurement to adults when they visit a primary healthcare center (also called family health center). It also aims to improve BP control in hypertensive patients by setting clinic BP targets. Technology will be used to measure adherance to these recommendations and track patient compliance and blood pressure control. The State Government of Kerala will be integrating indicators for hypertension in the Aadhar linked electronic  medical records captured by Kerala Government’s eHealth project. This is in accordance to the cochrane review on ‘Interventions used to improve control of blood pressure in patients with hypertension’, which recommended that primary care clinics need to have an organized system of regular follow-up and review of their hypertensive patients.

Find out more

This work on hypertension quality standards implementation in Kerala was recently presented by iDSI in the First NCD Congress in Chandigarh, India, you can view the presentation here. The final results from this work will be available next year and will contribute to the evidence base on how to improve detection and management of hypertension in low and middle income countries.

The recent report by the International Decision Support Initiative (iDSI) goes some way towards making the case for Health Technology Assessment (HTA) mechanisms in SSA to support more effective resource allocation when tackling this double burden. Hypertension was chosen as the case study, given its relatively high and growing prevalence in Ghana reaching up to 48% . An economic evaluation was undertaken based on an adaptation of a model developed for the 2006 update of the NICE guideline on hypertension management.

Seven key messages arise from this analysis, which made use of local Ghanaian data and policy-maker engagement:

1. Within the Ghanaian National Health Insurance remit, prescribing diuretics is estimated to cost an additional GH¢642 per DALY averted compared to no intervention.
2. Incremental cost per DALY avoided for Calcium Channel Blockers compared with diuretics is GH¢32,482.

Over the next 5 years Ghanaian authorities can

3. Save up to GH¢ 25,000,000, if they negotiate only a 10% reduction in average drug prices.
4. Save up to GH¢ 18,000,000 by encouraging only a 10% prescription shift from Calcium Channel Blockers to Diuretics, where clinically appropriate.
5. Save up to GH¢ 5,000,000 by encouraging a 10% shift from other drug classes to diuretics, where clinically appropriate.
6. Provide diuretic treatment to all patients with diagnosed but untreated hypertension using only a fraction of savings above (GH¢ 5,900,000) and can generate a net gain of 46,000 extra DALYs averted

Last but not least…

7. This report is an example of the value of being able to share HTA knowledge more freely, specifically executable economic models that can be adapted to local contexts. It demonstrates the positive impact of having open access sources for HTA knowledge dissemination on major health policy challenges worldwide.

To view the details of iDSI Ghana work including analytics, assumptions, and the data behind these key messages, download the report or view it here.

Incidentally, the drug sildenafil, originally tested for heart problems on the basis of its vasodilatory effects (which widens the blood vessels), can become a treatment for PAH patients. Despite its original intentions, in its first decade (1998-2008), the focus of the drug shifted from treating angina (chest pain), of which the treatment outcome was not satisfactory, to treating erectile dysfunction. As such, it became one of the most commercially successful drugs in the world. Its commercial successes did not incentivize companies to also register it for the indication to treat PAH despite many subsequent experiments, studies, randomized controlled trials, and clinician reports that say the little blue pill may actually be a good if not better treatment for PAH relative to other drugs.

In the case of Indonesia, an estimated number of 500 cases of PAH were reported in 2015. Currently, beraprost is the only available treatment approved for PAH by Indonesia’s national formulary. Local clinicians regard sildenafil as clinically more effective than beraprost. However, sildenafil is not listed in the national drugs formulary due to pharmaceutical companies’ non-registration of the product for the PAH indication. Some doses of sildenafil, e.g. 20 mg, for PAH indication is also not available in Indonesia Additionally, it is not included in the Indonesian benefits package of Jaminan Kasehatan Nasional (JKN).

To investigate its practical use in the Indonesian context, Indonesia’s Health Technology Assessment (HTA) Committee had commissioned a team to conduct a model-based economic evaluation and a budget impact analysis for using sildenafil as a first line treatment for PAH patients. This study was completed in the last quarter of 2015. There are reports that the government is considering allowing access to sildenafil for PAH through a Special Access Scheme.

In this effort, the Health Intervention and Technology Assessment Project (HITAP) Thailand, on behalf of the International Decision Support Initiative (iDSI) provided technical support to the team conducting the study. By embarking on this study, there is hope to providing better access to medicines in the country. We would like to acknowledge the Access and Delivery Partnership (ADP) for their support.