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Background The burden of cardiovascular diseases (CVDs) and response to health systems vary widely at the subnational level in India. Our study aimed to assess the variation in state-level access to medicines for CVDs by comparing the essential medicines lists (EMLs) at the national and subnational levels in India and by rapid appraisal of the existing policies and processes of drug procurement. Methods We assessed the inclusion of six classes of medicines for CVDs in the recent and publicly available national and subnational EMLs from July to September 2018 in the states of Telangana and Madhya Pradesh. We examined the drug procurement and distribution policies and processes using documentary review and five key informant interviews between March and June 2018. Results The WHO’s EML, India’s national EML, and 21 of 28 publicly available (75%) Indian state and Union Territory EMLs included all six classes of essential medicines for CVDs. However, some medicines were not included in the policy packages of essential medicines meant for primary health centres. Both the states used centralized tendering and decentralized distribution as part of the public sector drug procurement process. The requirement was based on the previous year’s consumption. The approximate time between procurement planning and distribution was 7–8 months in both the states. Conclusion Substantial variation exists in the selection of drugs for CVDs in EMLs at the subnational level in India. Improving forecasting techniques for requirement of medicines and reducing time lags between forecasting and distribution to health facilities may allow for better access to essential medicines.

Hypertension is the leading single preventable risk factor for death worldwide, and most of the disease burden attributed to hypertension weighs on low-and middle-income countries. Effective large-scale public health hypertension control programs are needed to control hypertension globally. National programs can follow six important steps to launch a successful national-scale hypertension control program: establish an administrative structure and survey current resources, select a standard hypertension treatment protocol, ensure supply of medication and blood pressure devices, train health care workers to measure blood pressure and control hypertension, implement an information system for monitoring patients and the program overall, and enroll and monitor patients with phased program expansion. Resolve to Save Lives, an initiative of global public health organization Vital Strategies, and its partners organized these six key steps and materials into a structured, stepwise guide to establish best practices in hypertension program design, launch, maintenance, and scale-up.

More than half of patients with hypertension require two or more medicines to control blood pressure. Combinations of anti‐hypertensive medicines are available as Single Pill Combinations (SPCs) or Single Agent Pills (SAPs). SPCs of two or more anti‐hypertensive medicines facilitate simpler dosing schedules, decrease pill burden, increase adherence to medicine, and simplify procurement and distribution. Despite this, equivalent combinations of separate pills (SAPs) are often prescribed instead of SPCs under the assumption that SAPs are priced lower. This study compared prices of anti‐hypertensive SPCs and equivalent SAPs in the private health care sector of India. High sales volume anti‐hypertensive SPCs and SAPs were selected from 2018 private sector pharmaceutical sales data. SPCs and SAPs price information was collected from online pharmacy websites between November 2019 and January 2020. Anti‐hypertensive SPCs represent approximately 39.1% of India's private sector anti‐hypertensive drug market. Multiple manufacturers produce the same top‐selling SPCs, suggesting a viable and competitive market. A comparison of SPCs and SAPs across different manufacturers showed that the lowest prices of both SPCs and the sum of component SAPs were nearly identical across different manufacturers. An analysis of dual‐drug SPCs and SAPs by the same manufacturer showed that most manufacturers (five of six) had priced their SPCs higher than SAPs. These observations suggest that the price of SPCs could be lowered to match the combined price of the component SAPs, and manufacturing costs and market forces do not present a barrier to the implementation of anti‐hypertensive SPCs.

Hypertension is a major public health challenge in low- and middle-income countries (LMICs) and calls for large-scale effective hypertension control programs. Adoption of drug and dose-specific treatment protocols recommended by the World Health Organization-HEARTS Initiative is key for hypertension control programs in LMICs. We estimated the annual medication cost per patient using three such protocols (protocol-1 and protocol-2 with Amlodipine, Telmisartan, using add-on doses and different drug orders, adding Chlorthalidone; protocol-3 with a single-pill combination (SPC) of Amlodipine/Telmisartan with dose up-titration, and addition of Chlorthalidone, if required) in India. The medication cost was simulated with different hypertension control assumptions for each protocol and calculated based on prices in the public and private sectors in India. The estimated annual medication cost per patient for protocol-1 and protocol-2 was $33.88–58.44 and $51.57–68.83 for protocol-3 in the private sector. The medication cost was lower in the generic stores ($5.78–9.57 for protocol-1 and protocol-2, and $7.35–9.89 for protocol-3). The medication cost for patients was the lowest ($2.05–3.89 for protocol-1 and protocol-2, and $2.94–3.98 for protocol-3) in the public sector. At less than $4 per patient per annum, scaling up a hypertension control program with specific treatment protocols is a potentially cost-effective public health intervention. Expanding low-cost generic retail networks would extend affordability in the private sector. The cost of treatment with SPC is comparable with non-SPC protocols and can be adopted in a public health program considering the advantage of simplified logistics, reduced pill burden, improved treatment adherence, and blood pressure control.

Background: India has a high burden of hypertension. While the private sector provides 70% of out-patient care in the country, a significant proportion of patients seeking care from the public sector buy drugs from private markets. This study aimed to describe India’s private sector antihypertensive drugs market at the national and state levels over 2016–2018. Methods: Antihypertensive drugs sales in India from 2016–2018 were analysed using a large nationally representative dataset for the private pharmaceuticals market. In addition, data for five states (Punjab, Madhya Pradesh, Kerala, Telangana, and Maharashtra) that were the foci of a large hypertension control program were studied. Results: The Indian hypertension drug market grew at a rate of 6.9% from 2016 to 2018 with a total of 21,066 million pills sales in 2018. Single-pill combinations (SPCs) contributed to 39.1% of total sale volumes. The market comprised of 182 different antihypertensive drugs including 134 SPCs. Total volume of sales covered a maximum of 26% of treatment need for the estimated population with hypertension. Two-drug SPCs had the highest market share (36%), followed by calcium channel blockers (18%), beta-blockers (16%) and angiotensin receptor blockers (14%). Among SPCs, amlodipine+atenolol had highest sales (9.8%). Twenty-five drugs, a mix of single drugs and SPCs, accounted for 80% of total sales. There were large state-to-state variations in sales per capita, preferred therapeutic classes and drugs. Conclusions: Despite the large antihypertensive drugs market, there exists a high unmet need for treatment in India. Inter-state differences in product sales indicate variable treatment practices, underscoring the need for private sector engagement to improve hypertension care practices aligned with national and international guidelines. SPCs contributed to a large share of the private market and inclusion of select antihypertensive SPCs in the national list of essential medications should be considered for the public health system.