Hypertension is a silent killer, claiming lives and livelihoods by developing into heart attacks, strokes and other cardiovascular diseases. More than a quarter of people in India are prone to this condition and yet only a few seek help or are detected by public health facilities. And, even among those who are registered as hypertensives in the public health care system, many miss clinical appointments for monitoring, medication and other services.
Image: rawpixel via Wikimedia Commons
Why do people not access public health services, though there is a system in place for low cost monitoring, medication and care, wondered Bidisha Das from the WHO Country Office, New Delhi. Along with Dinesh Neupane from the Johns Hopkins University, USA she investigated major reasons for missed appointments to characterize patient and health system barriers.
They collaborated with Health and Family Welfare Department officials to randomly select their sample. In 2019, there were about 14000 hypertensives registered in the digital system in Bathinda district, Punjab. Nearly 5000 of them had missed appointments for more than three consecutive months. The team randomly selected 300 and, after reviewing their medical records, tried to interview them telephonically. Their pre-structured questionnaire contained factors that may influence the dropout rate: the experience of the illness, financial constraints, self-treatment, lack of easy access to medical services and information, lack of social support,…
Some phone numbers, the team found, are constantly switched off, some of the selected respondents had died and some had actually not missed appointments – the first sign that the documentation system is still not fool-proof.
Out of the 206 respondents that they could ultimately manage, nearly half were enrolled in district and sub-district hospitals. Community health and primary health centers recorded lower enrolment.
Most patients who discontinued were above fifty. Interestingly, nearly sixty per cent were women, though it is well known that hypertension is more common among males. Thus, the sex of the patient was a factor in dropping out of the system.
About a quarter of the patients discontinued visits to the public health services due to the absence of any symptom. This implies that the information and consultancy provided in their earlier visits were inadequate as hypertensives require monitoring, if not medication. This is confirmed by another 15 per cent who did not come due to lack of specific instructions.
The distance to the facility was given as a reason by about one-fifth of the respondents. This was a major factor for discontinuation among older age groups.
Illness or disability, long waiting periods at the facility and concerns about the quality of medication were reasons offered by a small, but significant number of respondents. Interestingly, some patients report being discouraged by their social contacts as reason for not repeating visits.
The researchers found that most patients continued treatment from other sources, and a majority preferred private clinics. Some went to AYUSH practitioners, non-registered medical practitioners and some even relied on local chemists.
“There is a need for a more patient-centered health care system. Besides strengthening information systems for early detection, we need a system for managing missed visits”, says Bidisha Das, WHO.
“Along with the collection of patient information, there is a need to provide information and guide patients at public health facilities”, explains Sandeep Singh Gill, National Programme for prevention and control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, Chandigarh.
“We need a decentralized model of health service delivery, a model of health care that is appropriate to the local context, but is easily accessible, and reliable”, adds Gurinder Bir Singh, Ministry of Health and Family Welfare, Chandigarh.
Afshan Anjum Baba