
As Telangana experiences rapid economic growth, it is also seeing a rise in non-communicable diseases like hypertension, with over 30 percent of its population affected, including 25 percent in rural areas. The management of hypertension in these regions largely depends on local caregivers. Over 70 perent of out-patient care is by the private sector, and there are significant gaps in the management of this condition.
Rural Telangana faces significant challenges in hypertension management. Issues include a lack of routine checkups, high costs, the overreach of unqualified people who practise medicine, inconsistent measurement and treatment practices, and inadequate listening and counselling from providers.
These make for a suboptimal care experience for individuals with hypertension in these areas.
These findings have come to light in a recent study by the Indian School of Business (ISB). Researchers found significant discrepancies in how private healthcare providers manage the condition, highlighting the urgent need for a more standardised and organised approach.
The study was conducted by ISB’s Max Institute of Healthcare Management (MIHM). It revealed significant gaps in how hypertension is diagnosed and treated by private healthcare providers, especially in rural and peri-urban regions of India.
This qualitative study, published in the peer-reviewed journal BMC Health Services Research, is titled “Private provider practices and incentives for hypertension management in rural and peri-urban Telangana, India.”
The study involved in-depth interviews with over 46 healthcare professionals and patients from Warangal Urban, Karimnagar, and Sircilla districts in Telangana, where private healthcare is predominant. In rural Telangana, 41 percent of patients used private hospitals, and 37 percent visited private clinics.
Participants included various healthcare providers: modern medicine providers (MMPs), AYUSH practitioners, and informal rural medical practitioners (RMPs). The RMPs are often only trained to offer first aid and act as compounders but serve as medical practitioners.
The study also involved pharmacists, pharmaceutical sales representatives, and managers of diagnostic laboratories. Patient interviews helped cross-verify the findings from healthcare providers.
The findings
Routine hypertension screening was uncommon, with providers typically measuring blood pressure only when patients exhibited symptoms like dizziness.
Key findings point to inconsistent diagnostic practices, improper follow-up mechanisms and inadequate record-keeping, which hinder effective hypertension management.
A concerning revelation of the study is the lack of adherence to routine opportunistic screening protocols as private practitioners measure blood pressure only when patients exhibit explicit symptoms.
“The findings highlight that providers often rely on symptoms to initiate screening, rather than following the recommended practice of screening all adults,” said the study.
Arbitrary variation in diagnostic thresholds by private practitioners could delay the diagnosis, leaving patients devoid of treatment and at a heightened risk of complications.
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Inconsistencies and incentives
The ISB study highlights the lack of consistent follow-up routine, pointing out that the high costs of diagnostic tests discourage patients from seeing a specialist, stressing the need for financial aid to improve sustained long-term management of the disease.
Moreover, the lack of monitoring systems, poor record-keeping practices, and the absence of a structured follow-up mechanism hamper regular follow-up regime and treatment adherence, further compounding the crisis.
RMPs referred patients to MMPs and often received incentives in the form of cash, free medicine samples, or gifts like clocks or blood pressure monitors. Pharmacies and MMPs also received incentives based on sales and referrals from pharmaceutical companies.
Reputed medical practitioners have earlier cautioned against over-diagnosis of hypertension, as people are treated as an “ever-expanding marketplace for diseases”, to benefit commercial interests.
Patients in the ISB study confirmed they were often referred by local RMPs to specialists. Diagnostic labs were involved in further testing and also provided incentives to providers for referrals.
“The presence of incentives for referrals and prescriptions, such as commissions from diagnostic labs and pharmaceutical companies, can lead to over-diagnosis, over-treatment, and increased healthcare expenditure. This study provides new evidence on how these incentives operate in the context of hypertension care in rural and peri-urban India, with RMPs receiving incentives for referring patients to MMPs and diagnostic labs, and MMPs being influenced by the performance and incentives associated with specific drugs,” said the authors.
They added that these findings emphasise the need for policies and regulations that promote transparency and accountability in the healthcare system, such as mandatory disclosure of financial relationships and the implementation of clinical guidelines for evidence-based prescribing.
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Varied measurement and treatment
While the standard threshold was 140/90 mmHg for Blood Pressure measurement, the study found that some providers used higher readings, considering the patient’s age as a factor.
An AYUSH provider in Karimnagar explained, “For diastolic, the threshold is 90 plus the patient’s age. So, if a person is 40 years old, the threshold is 130.”
Providers used both mercury sphygmomanometers and digital devices, the latter preferred during home visits. Patients confirmed the variability in screening methods, with some diagnosed after one day of readings and others after a month.
The study also found that treatment methods differed across providers. Homoeopathy and Ayurveda practitioners used traditional formulations, while half of the RMPs offered lifestyle counselling and referrals. The remaining RMPs prescribed branded medications. This is illegal, as RMPs are not qualified to prescribe medicines.
MMPs typically started patients on low doses of medication and adjusted as needed.
A Warangal RMP said, “For the 60+ age group, I suggest irbesartan tablets… In other cases, amlodipine is prescribed based on their BP and condition.”
Pharmaceutical representatives indicated that drug prescriptions were influenced by effectiveness and incentives from pharma companies.
Listening and counselling
MMPs spent 10-15 minutes counselling patients on lifestyle changes and medication adherence. Recommendations focused on reducing salt intake, avoiding alcohol and tobacco, and encouraging exercise. RMPs personalised their advice based on patients’ occupations, especially for those in physically demanding jobs.
An RMP from Warangal stated, “If a patient is a labourer, I suggest staying hydrated and adjusting their workload according to the weather.”
While all providers claimed to follow hypertension treatment protocols, they did not offer specific details. Continuing Medical Education (CME) and peer meetings, often facilitated by pharmaceutical representatives, served as key knowledge sources. Providers in rural areas expressed the need for more CME opportunities to keep up with current practices.
An MMP in Warangal emphasised, “CMEs should focus more on rural areas, as most are conducted in cities like Hyderabad.”
There was no systematic follow-up process, with providers relying on patients to schedule visits. Only 20-30 percent of MMP patients adhered to regular follow-ups, with many only returning when symptoms worsened. Financial constraints, lack of awareness, and the misconception that long-term medication is not necessary contributed to low adherence.
A patient remarked, “After visiting the doctor for 2-3 follow-ups, I continued the same medication and only planned to return if any issues arose.”
Also Read: How 43 women from Kerala’s urban slums brought hypertension down in their community
Recommendation
To improve the outcomes, the ISB-MIHM study recommends compliance to standardised screening protocols and targeted educational interventions to address knowledge gaps and attitudinal barriers among private practitioners as well as patient education for enhanced self-management. It also suggests innovative financing models such as insurance or community health funds to lessen the economic burden on patients by minimising out-of-pocket expenditure.
Alongside systematic follow- up mechanisms such as patient outreach, community participation and digital monitoring tools, these measures can augment treatment adherence and overall hypertension management.
“Hypertension is often considered a health issue primarily affecting the affluent urban populations, but its prevalence is rising among lower income groups in rural and peri-urban areas, where access to formal healthcare is limited. This makes it crucial to develop public health programmes that engage with the healthcare providers at the local level to improve the quality of care and reduce the risk of complications,” said Prof. Sarang Deo, Executive Director, Max Institute of Healthcare Management and one of the co-authors of the study.
(Edited by Rosamma Thomas)
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