India has made significant strides in healthcare in the last few decades, including eradicating diseases like polio and reducing infant mortality rates. Moreover, to reduce the non-communicable disease burden, the National Programme for Prevention and Control of cancer, diabetes, cardiovascular diseases, and stroke (NPCDCS), launched in 2010, has helped save thousands of lives. The government has established 298 NCD cells under NPCDCS to provide services for early diagnosis and treatment for common NCDs.
Targeted interventions for NCDs like cardiovascular diseases and diabetes are commendable and the need of the hour is to prioritise stroke management with similar zeal and focus. A perusal of some factoids will help understand the urgency of the situation.
Stroke is the second commonest cause of death in India. In 2016, almost seven lakh people died because of stroke in India.
Alarmingly, stroke mortality rate is 1.4 times that of tuberculosis and 22 times that of malaria in our country.
Nearly one stroke case is reported every 40 seconds and one stroke death every four minutes.
Amongst survivors, stroke is also the most prevalent cause of chronic adult disability.
According to the Global Burden of Disease Study 2019, stroke was ranked as the second most common causes of health loss or Disability Adjusted Life Years (DALYs) in the 50–74-year and 75-years-and-older age groups and posed a significant burden in the 25-49 years age group.
Stroke is one of the largest contributors to increasing health loss in India over the last 30 years. Therefore, the Indian healthcare system needs a comprehensive approach for diagnosis and management of stroke, encompassing awareness amongst the masses and healthcare professionals (HCPs), robust infrastructure and stringent universal guidelines for stroke treatment.
The pandemic has enormously burdened our healthcare ecosystem, which has impacted care for NCDs. However, it is critical to understand that acute stroke requires urgent medical attention and cannot be compromised even during a healthcare crisis.
A stroke occurs when a blockage in the artery restricts blood flow to a part of the brain, resulting in cell death and damage. The clock starts ticking from the moment a person starts experiencing the symptoms of stroke. Proper medical attention and treatment must be administered during the “golden hours”, a window of 4.5 hours from the onset of symptoms, to avoid paralysis and save a life.
As per the Global Burden of Disease Study 2016, only one-fourth of stroke patients arrive at a medical care centre within six hours of experiencing the symptoms. Distance from a hospital, contact with a local doctor, and low-threat perceptions of symptoms were cited as independent factors for delay in arrival.It is, therefore, crucial to raise mass awareness about the symptoms of stroke. The FAST strategy (facial drooping, arm weakness, speech difficulties and time to call emergency services) is the best way to remember and identify stroke.
A widespread public awareness strategy is imperative to counter some of the misconceptions that exist around stroke. There are social and cultural beliefs that stroke is “an act of God”. In the past, we have seen such myths around polio vaccines being linked to impotency, resulting in vaccine hesitancy in certain communities. Similarly, vision loss due to cataract was considered as a curse/punishment from God for a crime committed by the sufferer or his family in a past life, thereby limiting the number of people opting for corrective surgeries. However, over the years, sustained awareness campaigns and community engagement have demystified these notions.
Atrial fibrillation (AF) is a major risk factor for stroke. A multi-centre observational study revealed that since AF related strokes are more severe, they result in higher treatment cost annually compared with non-AF related strokes in India.
The study conducted across key metropolitan cities in India highlighted that the total mean healthcare costs per patient including hospitalisation, follow-up with a general practitioner after discharge, specialist visits and screening procedures are close to Rs 5 lakh during the first year after surviving stroke. Other health care costs related to nursing care, home modifications, and informal care amounted to an average of Rs 69,000. During the first three months after discharge, patients with severe disabilities have 32 per cent higher costs than the ones with moderate disabilities.
Considering that our per capita income is lesser than other developing countries; and without a payor mechanism in place for stroke care, families of stroke patients suffer a significant financial burden. In instances where the family’s breadwinner is disabled due to stroke, a life-long fiscal liability can ensue.
The economic implications of stroke care and the rising disease burden warrant attention towards the inclusion of stroke care under the National Health Mission. A plausible start would be by introducing a dedicated neurological package under the Pradhan Mantri Jan Arogya Yojana (PMJAY), that covers the cost of thrombolysis, a treatment to dissolve clots in blood vessels to prevent stroke.
In the current guidelines of the PMJAY, acute ischemic stroke is mentioned under general medicine and paediatric medical management, whereas it is an emergency that requires immediate hospitalisation. The amount stipulated for thrombolysis is stated as INR 1800 in the Yojana, however, the actual cost is much higher than that.
Poor public awareness and inadequate infrastructure are two critical triggers for stroke-related mortality and morbidity burden in India.
India has one doctor for every 10,189 people and a deficit of 6,00,000 doctors currently. As per the National Health Profile 2018, the situation is worse in states like Uttar Pradesh and Bihar. Moreover, many Indian hospitals lack the necessary infrastructure required to treat stroke patients efficiently. The existing treatment gaps in stroke care and management include non-availability of stroke physicians round the clock, a dismal rate of 0.5 per cent of thrombolysis for stroke, lack of stroke units, and inefficient public emergency ambulance systems. All these factors contribute to the delay in the door-to-needle time.
Stroke diagnosis and management requires a multi-pronged approach which addresses the gaps that exist at each level.
Public advisories could play a key role in spreading mass awareness about the symptoms of stroke. Digital health records, as part of the government’s National Digital Health Mission (NDHM) will aid in maintaining a database of patients to study and evaluate the associated risk factors, disease progression and mortality rates, to shape future policies.
Public and private entities need to work in tandem to establish and mobilise resources at dedicated stroke units within the existing NCD cells at secondary and tertiary care hospitals. It is also critical to invest in training physicians to diagnose and manage stroke patients (including administering treatment), in the absence of a neurologist.
There are lessons to learn from states like Kerala that has a state-run NCD programme, Amrutham Arogyam which screens people above 30 years of age and provides free medicines for all detected with NCDs. The state recently won the United Nations Interagency Task Force (UNIATF) award for its outstanding contribution on prevention and control of NCDs.
States could possibly explore public-private partnerships to create centres of excellence for stroke care. This could essentially be a large tertiary care centre designated as a nodal centre and hub for leading all stroke-related activities for the state in coordination with the Department of Health and stroke experts. The centre would allow development and standardization of stroke awareness, education, referral and treatment etc. for medical colleges and district hospitals thus benefiting patients. Such hub-and-spoke models will certainly help achieve better patient outcomes.
The writer is Former Director General and Board Member, Organisation of Pharmaceutical Producers of India (OPPI)