Assessing India’s NCD preparedness in health systems: Methodological considerations

Sir,

The comprehensive national analysis by Srinivas et al¹ on the preparedness of India’s health facilities to manage type 2 diabetes (T2DM) and hypertension (HTN) is both timely and highly relevant¹. Its focus aligns with India’s ‘75/25’ initiative, which aims to place 75 million individuals with these conditions on standard care by 2025 under the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD)². Optimal service delivery is crucial to prevent the severe vascular complications arising from uncontrolled hypertension and poor glycaemic control. However, we wish to highlight several methodological and interpretive limitations in the study that warrant further consideration.

First, the authors refer to the ‘continuum of care’ in their analysis but do not provide an operational definition. A usual standard model for chronic diseases requiring lifelong treatment includes screening, diagnosis, pharmacological and non-pharmacological therapy, medication adherence, long-term follow up, and management of complications³. The study overlooks several of these components, particularly non-pharmacological services such as structured health education and tobacco cessation support. The omission of these services is a critical gap, as prior research has established that such deficiencies in primary care are linked to poorer patient outcomes in Indian health settings⁴.

Second, the key finding of high medication availability in public facilities should be interpreted with caution, which, while encouraging, does not account for systemic barriers that hinder patient access. In many Indian settings, chronic disease medications are dispensed for short durations (e.g., 2-4 wk), compelling frequent visits⁵. This practice, combined with high patient volume, long waiting times, and periodic drug stockouts, can lead to ‘drug holidays’ or force patients into out-of-pocket expenditure, undermining the effectiveness of public health services^6,7. Furthermore, to effectively measure medication adherence, Indian health facilities must be strengthened to systematically maintain patient prescription refill records, preferably in a digital format, which would enable calculating standardized metrics such as the Proportion of Days Covered (PDC)⁸.

Third, the study’s assessment of diagnostic capacity is limited in scope. It does not evaluate the availability of essential tests for monitoring, such as glycated haemoglobin (HbA1c), kidney function tests (including eGFR), and a lipid profile. The absence of these results during follow up is a well known driver of clinical inertia, leading to delayed initiation of vital therapies like insulin and statins and a failure to revise drug regimens in a timely manner based on declining patient renal function^9,10.

Finally, the ultimate measure of a health system’s effectiveness is its impact on patient health outcomes. The current analysis lacks data on short- and medium-term glycaemic and blood pressure control rates or the incidence of complications. This necessitates the accurate recording and prospective collection of such outcome data within health systems, ensuring accurate evaluation of the true effectiveness of our national health programmes.