WHO South-East Asia Journal of Public Health

: 2021  |  Volume : 10  |  Issue : 3  |  Page : 49--58

Decentralization of India Hypertension Control Initiative services to maintain continuum of care for hypertensive patients during COVID-19 pandemic in Telangana

T Sravan Kumar Reddy1, Abhishek Kunwar2, Kiran Durgad1, Fikru Tesfaye Tullu2, Chintala Sreedhar1, Abdul Wassey1, Anupam Pathni3, Leimapokpam Swasticharan4, Meenakshi Sharma5, Mallela Madhavi6,  
1 WHO India-supported India Hypertension Control Initiative, Telangana, India
2 WHO Country Office for India, New Delhi, India
3 Resolve to Save Lives, New Delhi, India
4 Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi, India
5 Indian Council of Medical Research, New Delhi, India
6 State Non-Communicable Disease Cell, Directorate of Health Services, Hyderabad, Telangana, India

Correspondence Address:
Dr Kiran Durgad
WHO India-supported India Hypertension Control Initiative, Telangana


The India Hypertension Control Initiative (IHCI) was launched in Telangana, India, with the vision of maintaining the continuum of care for hypertensive patients and improving treatment outcomes through provision of free hypertension medication. Decentralization of the IHCI towards more patient-centred services was undertaken to bring free medication and follow-up services closer to the community in the hopes of improving follow-up and control rates for hypertensive patients. To determine if decentralization of hypertension follow-up services and free medication to peripheral health centres improved continuity of care and treatment outcomes in hypertensive patients and helped to mitigate disruption during the coronavirus disease 2019 (COVID-19) pandemic, hypertension outcomes were reviewed before and during the COVID-19 pandemic, for patients registered in health centres that decentralized free medication and follow-up services to subcentres – the intervention group – and in health centres that did not decentralize these services – the non-intervention group. Hypertensive patients had higher rates of monthly follow-up and controlled blood pressure in the decentralized facilities than in the non-decentralized facilities, where these services were limited to primary and secondary health centres. Comparing follow-up rates and blood pressure control rates before and during the COVID-19 pandemic, these were maintained for patients in the decentralized facilities whereas they were significantly lower for patients in the non-decentralized facilities. The IHCI decentralized model appears to have contributed to continuity of care for people with hypertension and to have maintained this continuity against system shocks such as that of the COVID-19 pandemic. Decentralization of free medicines and follow-up services to the first and most peripheral point of contact in the primary health care system brings these essential services closer to home, which can encourage patients to seek services from the public sector – capturing a strong case for a primary health care foundation to the strengthening of systems for universal health coverage.

How to cite this article:
Reddy T S, Kunwar A, Durgad K, Tullu FT, Sreedhar C, Wassey A, Pathni A, Swasticharan L, Sharma M, Madhavi M. Decentralization of India Hypertension Control Initiative services to maintain continuum of care for hypertensive patients during COVID-19 pandemic in Telangana.WHO South-East Asia J Public Health 2021;10:49-58

How to cite this URL:
Reddy T S, Kunwar A, Durgad K, Tullu FT, Sreedhar C, Wassey A, Pathni A, Swasticharan L, Sharma M, Madhavi M. Decentralization of India Hypertension Control Initiative services to maintain continuum of care for hypertensive patients during COVID-19 pandemic in Telangana. WHO South-East Asia J Public Health [serial online] 2021 [cited 2022 Jan 25 ];10:49-58
Available from: http://www.who-seajph.org/text.asp?2021/10/3/49/309873

Full Text


Hypertension, or high blood pressure (BP), affects an estimated 1.13 billion people globally. Known as the silent killer, it is a major cause of premature mortality, including cardiovascular disease and stroke, the top two causes of death worldwide.[1] In India hypertension contributes to an estimated 1.6 million deaths a year due to cardiovascular diseases, with an estimated 200 million Indians having high BP, of whom fewer than half are aware of their condition, and fewer than one tenth have their BP under control.[2]

The Government of India has set ambitious targets in response to this disease burden: by 2025, a 25% relative reduction in the prevalence of hypertension, and 80% controlled BP among people known to have hypertension.[3],[4] Attaining these targets means sustained treatment of approximately 45 million hypertensive people – no small feat especially if half are unaware of their condition. To address this lack of awareness, the Government of India has implemented a widespread population-based hypertension-screening programme at the community level. However, with the chronic nature of hypertension, its management and control require pervasive reach into communities and an integrated primary health care approach to sustain lifelong connections to care.

India Hypertension Control Initiative

The India Hypertension Control Initiative (IHCI) is a multipartner initiative of the Ministry of Health and Family Welfare (MoHFW), Government of India; the Indian Council of Medical Research (ICMR); state governments in India; the World Health Organization (WHO) India; and Resolve to Save Lives (a technical partner). It was launched in late 2017 to strengthen hypertension management and monitoring at the primary health care level. With the evidence-based strategies adopted from the technical package of the Global Hearts Initiative for the treatment of hypertension in primary care services, the IHCI promotes five components of care needed to effectively reduce hypertension: implement practical treatment protocols to ensure consistent quality, ensure regular uninterrupted supply of hypertension drugs free of cost, employ team-based care and task shifting, focus on patient-centred services, and establish information systems [Box 1].[5] By ensuring the continuum of quality care for patients detected with hypertension, the IHCI complements population-based screening and is expected to accelerate the progress towards the achievement of Government of India targets, as well as to contribute to those of universal health coverage and the Sustainable Development Goal 3 target of reducing premature mortality from noncommunicable diseases (NCDs) by 30% by 2030. Starting in 2018, the IHCI was rolled out in a phased manner to five states [Box 1]. By July 2019, based on successes and lessons learnt, the MoHFW announced Phase 2 of IHCI, with plans to expand to 100 districts covering most of India, with the aim of reaching 150 million people by 2023.[6][INLINE:1]

India Hypertension Control Initiative in Telangana state

In this paper we focus on IHCI implementation in the southern state of Telangana. The newest of India’s states, Telangana has the eighth largest state economy, with a population of 35 million. The most recent population-based survey found hypertension prevalence of 13% in women and 21% in men (2016).[7] Another study reported for Telangana estimates along the hypertension cascade of care: 80.5% of people with hypertension screened, 55% aware of their condition, 16.4% treated for their BP and 9.4% having their BP under control.[1]

IHCI roll-out to its 10 districts started in November 2018 [Box 1]. [Figure 1] describes the IHCI in relation to the health service delivery structure in India. Initially the IHCI was focused on the primary health centres (PHCs) and secondary care facilities up to the level of district hospital, where, after diagnosis, hypertensive patients were registered, counselled and provided with optimized treatment and a cost-free 1-month supply of medication.[5] Every registered patient received a hypertensive treatment card (HTC) to track his or her follow- up visits and BP. A team of cardiovascular health officers and cardiovascular health senior treatment supervisors provided technical support and monthly monitoring through facility visits.{Figure 1}

During the initial stages of implementation there were lessons learnt on successes and limitations of the IHCI [Box 1]. Notably, more than a third of facilities implementing IHCI had over half of their registered patients missing follow-up visits, meaning they were not accessing their free medication and BP checks. When nurses tracked these patients by phone, the main barriers patients conveyed included the distance to travel to the PHC, the high out-of-pocket cost of transport to get to the PHC and the loss of wages for time off to travel to the PHC. Patients further indicated that, since hypertension medicines cost less than US$ 1 per month, visiting the PHC for free medication would not offset the cost they would incur to get there. More patient-centred approaches were needed to address these barriers and ensure continuity of care.

Patient-centred services: decentralization of IHCI

Experience from other countries and India’s HIV/AIDS and tuberculosis programmes have shown decentralization approaches do address many barriers to access and can deliver chronic care services closer to communities.[8] In this sense, decentralization refers to prioritizing community-level access to care through the transfer of clinical decisions and tasks often considered the responsibility of only highly trained specialists to general care providers and lay health workers (task shifting), and the transfer of associated pharmaceuticals, health commodities and equipment to community-level and peripheral health facilities. Realizing that decentralization of services is one of the key elements of primary health care that can address geographical barriers to access, high out-of- pocket costs and retention issues of chronic patients requiring lifelong medication and regular follow-up, it was decided, with the support of the Telangana state government, to decentralize the IHCI.[9]

[Figure 1] highlights the process and details of decentralization. To address the issues in continuity of care, follow-up services for hypertensive patients registered in IHCI, on treatment and with controlled BP – monthly monitoring of BP and dispensing of drug refills – were decentralized from the PHC to the subcentres. Each PHC has five or six associated subcentres, which are the most peripheral health facilities and first points of contact between the health system and the community. Sanctioned staff in Telangana’s subcentres include two female auxiliary nurse midwives (ANMs), who provide essential community health services and manage records of vital statistics, catering to a population of around 5 000.

As a pilot in the first quarter of 2019, IHCI services were decentralized to the subcentres of nine PHCs across six districts, with the plan of scaling up in a phased manner to all PHCs in the state, contingent on positive preliminary findings. PHC nurses coordinated the decentralization process with support from cardiovascular health officers and cardiovascular health senior treatment supervisors. ANMs were trained to measure BP, dispense drug refills and manage patient data, while BP monitors and antihypertensive drugs were made available at the subcentres. Patients registered at these decentralized facilities, who were on treatment and with controlled BP, were invited to avail themselves of follow-up services from the subcentres. ANMs would provide these patients with their monthly follow-up care, including BP measurement, drug refills and cohort monitoring through manual treatment cards. In addition, if patients’ BPs were uncontrolled, they were referred to the PHC for assessment by a medical doctor.

The decentralization was facilitated by the Government of India-supported accredited social health activists (ASHAs) – the first port of call for any health-related need in the community.[10] ASHAs serve as the interface between their communities and the formal public health system, providing communitylevel curative care, raising awareness of health-related social determinants and entitlements, and mobilizing and facilitating people’s access to public health services.[11] Piggybacking on their ongoing support for hypertension screening, ASHAs educated their communities about the new decentralized services at the subcentres and the value of registering at the PHC so they could access the free hypertension medication and follow-up services at these subcentres. ASHAs were also provided with line lists of registered hypertensive patients in their communities so they could mobilize them to visit the subcentres for follow-up.

COVID-19 and disruption of IHCI services

By the time WHO declared the COVID-19 pandemic in March 2020, IHCI decentralization had rolled out to all the subcentres in 6 of Telangana’s 10 districts. Telangana’s first case of COVID-19 was detected on 2 March 2020, after which the case load gradually increased. To combat the spread of COVID-19 in India, a nationwide mobility restriction, or lockdown, which stopped most public transport, was declared from the end of March 2020 until the end of May 2020, after which there was a phased relaxing of restrictions. To respond to the steady increase in COVID-19 cases, all PHCs were designated as COVID-19 testing centres and much of the health workforce was repurposed to COVID-19-related activities.[12],[13]

During the pandemic, many countries reported disruptions in the diagnosis and treatment of NCDs.[14] As people with hypertension are more prone to severe illness and complications of COVID-19, it was critical to ensure the continuum of care for these patients in the face of potential disruption.[12] At the national level, the Government of India identified the provision of medication for hypertension as a priority for maintaining essential services, which allowed decentralization efforts to continue. A preliminary review of Telangana’s IHCI monthly cohort data on hypertension outcomes suggested services may have been disrupted as a result of the pandemic and/or lockdown; just prior to the pandemic, in February 2020, nine districts had at least 50% of their patients controlled for BP, compared with only four districts in August 2020, 5 months after the pandemic had started. In response to these initial findings, Telangana state responded by having subcentres mobilize drugs for further distribution to patients during the lockdown period. With the use of the IHCI line list of patients, ASHAs and ANMs went from door to door and delivered the medicines at the patients’ doorsteps. Consequently, we wanted to look more closely at whether or not the COVID-19 pandemic affected IHCI follow-up services and hypertension outcomes, and if the decentralization of these IHCI services helped to mitigate their disruption.


We reviewed hypertension outcomes before and during the COVID-19 pandemic, for patients registered (i) in PHCs that decentralized their follow-up services to subcentres, the intervention group, and (ii) in PHCs that did not decentralize these services, the non-intervention group. [Figure 2] illustrates the differences between these two study groups. For the intervention group, the decentralization of follow-up services included the training of ANMs, availability of hypertensive drugs at the subcentre, the availability of BP monitors and the transfer of treatment cards from the PHC to the subcentre.{Figure 2}

At the PHC, all patients are newly registered in the IHCI, which has been implemented in both the intervention and non-intervention groups with the same treatment protocols, supportive supervision system, drug supplies, availability of functional BP monitors, and recording and reporting system. Both patient study groups receive the same services (numbered 1–4 in [Figure 2]). At the time of the monthly follow-up, the intervention group’s services have been decentralized to the subcentre, while the non-intervention group’s follow-up visits continue at the PHC. Both study groups have access to the same follow-up services as listed in [Figure 1] – monthly BP monitoring, dispensing of prescribed refills if BP is under control, counselling as needed and documentation of the visit in the patient’s HTC. The difference between the two is that the intervention group receives these services in the subcentre administered by an ANM, and the non-intervention group receives these services at the PHC administered by a nurse. If the patient’s BP is not under control, the patient is referred to the medical doctor, who for the non-intervention patient is at the same facility, the PHC, whereas the intervention patient must travel to the PHC for the doctor consultation and possible titration of medicines.

The hypertension outcomes of patients newly registered in IHCI were determined over three cohort periods. [Table 1] provides the summary characteristics of the three study cohorts. The first cohort, from the second quarter of 2019, is pre- COVID-19, and drawn from nine decentralized (intervention) and nine non-decentralized (non-intervention) PHCs from the same six districts during the pilot phase, retrospectively matched on health facility attributes and population coverage. Similarly, a second set of cohorts was drawn from 2020 during the COVID-19 pandemic, from all PHCs in a fully decentralized district (intervention) and in a non-decentralized district (nonintervention). The two districts were retrospectively matched on population size and health system attributes [Table 2]. The two study cohorts are based on different sampling approaches. The 2020 6-month cohort includes all patients newly registered in the IHCI between January and June 2020, from all PHCs in both the intervention and non-intervention districts. The monthly cohort is three separate 1-month samplings (March, April, May 2020) of 50 patients from all the PHCs in both districts.{Table 1}{Table 2}

We analysed two primary indicators along the continuum of care: the follow-up rate and the BP control rate. The operational definitions are in [Table 1]. The data collection and data entry were the same for all three cohorts. The HTCs of all newly registered patients between the relevant dates for each cohort and in both the intervention and non-intervention districts were reviewed. For each patient, the HTC was checked to determine if at least one follow-up visit had been made at any time during the relevant time period. If there was a follow-up visit, an e-record was made if the BP result was recorded and if the patient received a refill prescription or was referred to the PHC. Chi-square significance testing of comparisons was done in Epi Info 7.2 for the 2020 6-month cohort only.


Entry into IHCI

[Table 1] summarizes select characteristics for the intervention and non-intervention study groups for all five cohorts. While health system characteristics are matched quite equally between the two study groups across all cohorts, the number of newly registered patients during the study period is substantially higher in the intervention groups. For the 2019 pilot, nearly three times as many patients were newly registered into IHCI at the decentralized facilities as at the non-intervention facilities. Similarly, for the 2020 6-month cohort, the number of newly registered patients in the decentralized intervention group is nearly 1.5 times as many as in the non-intervention group. This difference is not explained by differences in the district population. The intervention district (Mulugu) in the 2020 cohorts has a smaller population than the non-intervention district (Jayashankar Bhupalpally), and for the 2019 pilot the populations are similar. One explanation for the pronounced difference could be the influx of hypertensive patients not previously captured by the public sector and perhaps treated in the private sector; in fact, one study found that 91% of newly registered patients in Telangana IHCI sentinel sites had been previously diagnosed with hypertension.[6]

Follow-up visits and controlled blood pressure

Across all cohorts, the follow-up rate was higher for the intervention groups than for the non-intervention groups (see [Figure 3]). This means that the decentralized facilities/districts had a higher percentage of newly registered IHCI patients who attended at least one monthly follow-up visit during the assessed outcome period, ranging from 65% for the April 2020 monthly cohort to 86% for the 2019 pilot cohort. In contrast, the non-decentralized facilities/districts had follow-up rates ranging from 36% for the March 2020 cohort to 65% for the 2019 pilot cohort.{Figure 3}

The BP control rates had similar patterns to the follow-up rates and were higher in the intervention groups than in the nonintervention groups (see [Figure 3]). Among all newly registered IHCI patients, a higher percentage of those accessing decentralized facilities/districts had their BP under control – 74% for the 2019 pilot cohort (which is close to the national target of 80%) and 61% for the April 2020 cohort – compared with patients from non-decentralized facilities/districts (65% for the 2019 pilot cohort and 32% for the April 2020 cohort).

Differences in follow-up and hypertension control rates were statistically significant (p < 0.001) for the 2020 6-month cohort, and for the 2019 pilot the sample sizes render the difference in rates considerable.

These results suggest that, across different time and geographic variables, decentralizing follow-up services may improve continuity of care and bring the programme closer to national goals.

IHCI before and during COVID-19 pandemic

The follow-up assessments of the 2020 monthly cohorts span the same period as the Telangana COVID-19 lockdown: April 2020 to June 2020. Across all three monthly cohorts and for both intervention and non-intervention groups, the follow- up and BP control rates were lower than those of the pre- COVID-19 pilot, suggesting that some level of disruption to service delivery took place during the COVID-19 lockdown, regardless of decentralization status [Figure 3].

However, the magnitude of disruption during COVID is much more pronounced in the non-intervention groups. For example, for the decentralized groups, the follow-up rate was 86% in the 2019 pilot cohort and 78% in the March 2020 cohort, a 9% difference. In contrast, for the non-intervention groups, the follow-up rate was 74% in the 2019 pilot cohort and 36% in the March 2020 cohort, a decrease of 51%. This pattern, of a less substantial decline in follow-ups among the decentralized services, was observed for all monthly cohorts. These results point to a potential protective effect of decentralization against disruption of essential services under constrained conditions, such as the COVID-19 pandemic. Interestingly, even though the period of follow-up assessment for the 2020 6-month cohort took place during the phased relaxation of lockdown, the follow-up and control rates were consistent with those of the monthly cohorts.

[Figure 4] shows for each cohort and by study group the distribution of newly registered patients’ status at their assessed follow-up: controlled BP, uncontrolled BP or missed visit. The figure provides a more comprehensive picture of who is not included as having their BP controlled, which can shed light on service delivery priorities to address these patients’ unmet needs across different settings and conditions. Missed patients have an unknown BP status, so the priority is to have their BP measured, while the patients with uncontrolled BP require possible titration of their medicines, so their immediate priority is to access a medical doctor at the PHC. In this study, except for the 2019 pilot cohort, missing patients from non- decentralized facilities were a substantially higher percentage than patients with uncontrolled BP. In contrast, except for the April 2020 cohort, the percentages of uncontrolled and missing patients from decentralized facilities are similar. In both cases the aim is to ensure they have the medicines they need to control their BP, but the approaches to achieve this are different with their own set of challenges. For patients with uncontrolled BP, if they are unable to access the PHC, the subcentre does not offer titration of medicines. Complementary approaches are needed to ensure these patients get the care and medicines they need.{Figure 4}

Strengths and limitations

This study highlights the effective use of routine data to evaluate implementation outcomes, including in the context of a significant public health emergency, demonstrating trends that provide important insights into the importance of access to affordable medicines and potential benefits of decentralization. A significant limitation is that the findings here are observational and that factors not controlled for may have influenced the outcomes in ways that have not been documented. Comparison of results between the 2019 and 2020 cohorts has its limitations, since the time periods and population groups are different. This could introduce confounding factors that bias findings. Furthermore, the full impact over time of COVID-19, the lockdown, and additional interventions such as the home deliveries of medication by ANMs and ASHAs on each 2020 cohort has not been analysed.


Evidence shows that the IHCI has had a substantial impact on service availability, utilization and health status, sustained even during COVID-19; a study of 24 sentinel clinics across four states in India found that the patients from Telangana had the highest follow-up rate (73%) and BP control rate among those returning for follow-up (78%).[6] An analysis of the underlying reasons for this highlights the importance of primary health care for improved service delivery. This provides a useful contribution to the discussion on both specific areas of strengthening health systems for primary care and the importance of an overarching primary health care approach for universal health coverage.

The IHCI is designed to be anchored in communities at the primary care level, with referrals to higher-level facilities. At the core of the service delivery effort is the regular supply of hypertension drugs, free of cost and backed up by the availability of trained health workers, appropriately managed using task shifting and team-based care, and monitored with the support of the health information system.

The cost of medicines to households in India is notably high. Out-of-pocket expenditure makes up 60% of total health spending, of which 40% is on medicines, and 90% of all the expenditure on medicines and diagnostics is borne by households.[15] Public investment in medicines has remained persistently low in India in spite of the international evidence on its importance for both utilization and equity in low-income settings. A recent study in Tanzania found health service utilization positively and significantly associated with the continuous availability of all essential medicines.[16] A study in Chhattisgarh, India, found that 70% of overall household out- of-pocket expenditure was for medicines, which was a key barrier to access, reinforcing the recommendation to implement lists of essential drugs.[17] Addressing access to medicines is at the heart of the IHCI design, and its implementation supports this evidence. Findings from this study indicate that improving access to affordable (free) prescription drugs affected the utilization of services from the public sector.

Conceptually, community health workers are an integral part of primary care; however, experience has shown a number of challenges owing to both systems gaps and the overall context in which guidelines and best practices are applied and replicated.[18] One study assessed the opportunities and challenges to the roles and responsibilities of ASHAs in Manipur, India, and found they were critically constrained by overall system limitations, including poorly equipped facilities and capacity of health workers.[19] This not only affected their work but also eroded trust and credibility in the community. The IHCI experience suggests that addressing strengthening systems in programme design and its operationalization through systemic support for health workforce can be effective in supporting frontline providers such as ASHAs in their interrelated health and community roles.

A key enabler for successful implementation of the IHCI has been the decision to decentralize the procurement and distribution of (free) medicines and service delivery to the first point of contact. Decentralization was further supported by capacity strengthening at community and peripheral health facility levels, notably through the training of ANMs and ASHAs in new clinical skills, monitoring and evaluation, health education and counselling, pharmaceuticals and supply chain. Importantly, health workers were mobilized to inform communities of the availability of services and medicines and encourage utilization. The higher number of registered patients in decentralized districts and facilities suggests that ASHAs were instrumental in linking communities to key public health services.

Globally, the evidence on health service decentralization is mixed. A systematic review of the experience of 26 lower- and middle-income countries found that impact was dependent on technical and decision-making capacities at decentralized level; and, while effectiveness in governance, financing and service delivery appears to have improved with decentralization, resource management seems to be less so.[20] Similar single- country reviews in Indonesia[21] and India[22] highlight the need for more research for conclusive results. Decentralization has been a crucial factor in the success of the IHCI and, while this study does not consider the issue in depth, its findings do contribute to the knowledge pool and, in line with the Muñoz et al. review, indicate the potential of decentralization when accompanied by requisite conditions. Programme data indicate there were substantially more newly registered hypertensive patients in the decentralized study group than in the non- decentralized study group, including during the COVD-19 pandemic. Decentralization also appears to have contributed to improved continuity of care. Hypertensive patients had higher rates of monthly follow-up in the decentralized study group than the patients in the non-intervention study group, where these services were limited to the PHC. Across all the study cohorts, patients from the decentralized facilities had higher BP control rates than patients from the non-intervention facilities. Moreover, across the 2020 cohorts, the follow-up and BP control rates for groups in decentralized areas were maintained, not deviating significantly from the 2019 cohort rates, despite the concurrent lockdown and rising COVID-19 burden. The groups in non-decentralized areas experienced follow-up and BP control rates that were half of those in the pre-COVID-19 cohort.

It is important to acknowledge that the programme was not without challenges: maintenance of regular and adequate stocks of drugs; persistent shortages of sanctioned ANMs at the subcentres (retention of staff at the community health level is an overarching systems challenge);[23] the cumbersome paper-based approach of HTCs (again, a continuing issue in relation to health management information systems); and gaps in continuity of care for patients unable to access the PHC through, for example, telemedicine consultations with the ANM and patient, or NCD camps at the community level where medical doctors visit monthly or bimonthly to provide medication titration and other follow-up services for patients with uncontrolled BP who are unable to access the PHC. Nevertheless, IHCI has made significant achievements as well as maintaining continuity of services even through the pandemic, with important lessons for building resilient health systems and primary health care.


The IHCI decentralized model appears to have contributed to the continuity of care for people with hypertension and to have maintained this continuity against system shocks such as that of the COVID-19 pandemic. Decentralization of free medicines and follow-up services to the first and most peripheral point of contact in the primary health care system brings these essential services closer to home, which can encourage patients to seek services from the public sector. Now, more than ever, the new normal requires more decentralized service delivery models that deliver care where and when it is required, reaching the patients who are in need.

Acknowledgements: We would like to acknowledge the Government of Telangana for supporting the implementation of the IHCI and Dr Prabhdeep Kaur, Principal Investigator (IHCI), for technical guidance. We thank cardiovascular health officers, senior treatment supervisors, doctors, nurses and all health officials in various project districts for implementing IHCI strategies.

Source of support: The IHCI project is jointly funded by WHO and the Indian Council of Medical Research, India. The Ministry of Health and Family Welfare and state governments fund the NCD activities in the government primary and secondary care facilities under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke.

Conflict of interest: None declared.

Authorship: All authors contributed equally to this paper.


1Prenissl J, Manne-Goehler J, Jaacks LM, Prabhakaran D, Awasthi A, Bischops AC et al. Hypertension screening, awareness, treatment, and control in India: a nationally representative cross-sectional study among individuals aged 15 to 49 years. PLoS Med. 2019;16(5):e1002801. https://doi.org/10.1371/journal.pmed.1002801 PMID:31050680
2World Health Organization. Hypertension (https://www.who.int/health-topics/hypertension/#tab=tab_1, accessed 28 October 2020).
3National multisectoral action plan for prevention and control of common NCDs (2017–2022). New Delhi: Ministry of Health and Family Welfare, Government of India; 2017 (https://main.mohfw.gov. in/sites/default/files/National%20Multisectoral%20Action%20Plan%20 %28NMAP%29%20for%20Prevention%20and%20Control%20 of%20Common%20NCDs%20%282017-22%29_1.pdf, accessed 30 October 2020).
4National health policy 2017. New Delhi: Ministry of Health and Family Welfare, Government of India; 2017 (https://www.nhp.gov. in//NHPfiles/national_health_policy_2017.pdf, accessed 22 October 2020).
5World Health Organization. HEARTS technical package (https://www. who.int/cardiovascular_diseases/hearts/en/, accessed 29 September 2020).
6Kaur P, Kunwar A, Sharma M, Mitra J, Das C, Swasticharan L et al. India Hypertension Control Initiative: hypertension treatment and blood pressure control in a cohort in 24 sentinel site clinics, India. J Clin Hypertens (Greenwich). 2020;00:1–10. https://doi.org/10.1111/ jch.14141 PMID:33369074
7International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), 2015–16: India. Mumbai: IIPS; 2017 (https://dhsprogram.com/pubs/pdf/FR339/FR339.pdf, accessed 26 January 2021).
8Gupta N, Bukhman G. Leveraging the lessons learned from HIV/ AIDS for coordinated chronic care delivery in resource-poor settings. Healthc (Amst). 2015;3(4):215–20. https://doi.org/10.1016/j. hjdsi.2015.09.006 PMID:26699346
9Legido-Quigley H, Naheed A, de Silva HA, Jehan I, Haldane V, Cobb B et al. Patients’ experiences on accessing health care services for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: a qualitative study. PLoS One. 2019;14(1):e0211100. https://doi.org/10.1371/journal.pone.0211100 PMID:30682093
10National Health Mission, Ministry of Health and Family Welfare, Government of India. About Accredited Social Health Activist (ASHA) (https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=150&lid=226, accessed 27 January 2021).
11Guidelines for ASHA and Mahila Arogya Samiti in the urban context: National Urban Health Mission. New Delhi: Ministry of Health and Family Welfare, Government of India; 2014 (https://nhm.gov.in/images/pdf/NUHM/Guidelines_for_Asha_and_MAS_in_Urban_Context.pdf, accessed 26 January 2021).
12Huang S, Wang J, Liu F, Liu J, Cao G, Yang C et al. COVID-19 patients with hypertension have more severe disease: a multicenter retrospective observational study. Hypertens Res. 2020;43(8):824–31. https://doi.org/10.1038/s41440-020-0485-2 PMID:32483311
13Enabling delivery of essential health services during the COVID-19 outbreak: guidance note. New Delhi: Ministry of Health and Family Welfare, Government of India; 2020 (https://www.mohfw.gov.in/pdf/EssentialservicesduringCOVID19updated0411201.pdf, accessed 10 October 2020).
14World Health Organization. In WHO global pulse survey, 90% of countries report disruptions to essential health services since COVID-19 pandemic; 31 August 2020 (https://www.who.int/news/ item/31-08-2020-in-who-global-pulse-survey-90-of-countries-report- disruptions-to-essential-health-services-since-covid-19-pandemic, accessed 22 October 2020).
15National Health Systems Resource Centre. National health accounts estimates for India 2016–17. New Delhi: Ministry of Health and Family Welfare, Government of India; 2019 (http://nhsrcindia.org/sites/default/files/FINAL%20National%20Health%20Accounts%202016- 17%20Nov%202019-for%20Web.pdf, accessed 26 January 2021).
16Kuwawenaruwa A, Wyss K, Wiedenmayer K, Metta E, Tediosi F. The effects of medicines availability and stock-outs on household’s utilization of healthcare services in Dodoma region, Tanzania. Health Policy Plan. 2020;35(3):323–33. https://doi.org/10.1093/heapol/ czz173 PMID:31942625
17Tripathi N, Kerketta F, Chatterjee P, Raman VR, John D, Jain K. Access and availability of essential medicines in Chhattisgarh: situation in public health facilities. J Family Med Prim Care. 2018;7(1):152–6. https://doi.org/10.4103/jfmpc.jfmpc_78_17 PMID:29915750
18WHO guideline on health policy and system support to optimize community health worker programmes. Geneva: World Health Organization; 2018. (https://apps.who.int/iris/bitstream/hand le/10665/275474/9789241550369-eng.pdf?ua=1, accessed 26 January 2021).
19Saprii L, Richards E, Kokho P, Theobald S. Community health workers in rural India: analysing the opportunities and challenges accredited social health activists (ASHAs) face in realising their multiple roles. Hum Resour Health. 2015;13:95. https://doi. org/10.1186/s12960-015-0094-3 PMID:26646109
20Muñoz DC, Amador PM, Llamas LM, Hernandez DM, Sancho JMS. Decentralization of health systems in low and middle income countries: a systematic review. Int J Public Health. 2017 Mar;62(2):219–29. https://doi.org/10.1007/s00038-016-0872-2 PMID:27572495
21Rakmawati T, Hinchcliff R, Pardosi JF. District-level impacts of health system decentralization in Indonesia: a systematic review. Int J Health Plann Manage. 2019;34(2):e1026–e1053. https://doi.org/10.1002/hpm.2768 PMID:30901111
22Panda B, Thakur HP. Decentralization and health system performance: a focused review of dimensions, difficulties, and derivatives in India. BMC Health Serv Res. 2016;16(Suppl. 6):561. https://doi.org/10.1186/s12913-016-1784-9 PMID:28185593
23Abimbola S, Olanipekun T, Igbokwe U, Negin J, Jan S, Martiniuk A et al. How decentralisation influences the retention of primary health care workers in rural Nigeria. Glob Health Action. 2015;8:1. https:// doi.org/10.3402/gha.v8.26616 PMID:25739967