PRIVATE HEALTH SECTOR PREFERENCES IN TREATMENT OF HYPERTENSION IN INDIA: EVIDENCE FROM HYPERTENSION DRUGS MARKET DATA

Objective: In India, there are an estimated 200 million adults with high blood pressure. National and international guidelines recommend calcium channel blockers (CCB), diuretics, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) for first line treatment of uncomplicated hypertension, while beta-blockers (BB) have been relegated to second-line treatment. As the private sector provides 70% of out-patient care in the country, we assessed private health sector preferences of antihypertensive medications using market data. Design and method: Sales of all antihypertensive formulations in India from 2016–2018 were analysed, using a large nationally representative dataset for the private sector pharmaceuticals market. In addition to analysis at the National level, data for five states was analysed to determine any inter-state variations. Results: The Indian hypertension drug market grew at a compounded annual growth rate of 6.9% from 2016 to 2018 with a total of 21,066 million tablet or capsule sales in 2018. Two-drug single pill combinations (SPCs) had the highest market share in 2018, with 36% of market volumes, followed by CCBs (18%), BBs (16%), ARBs (14%), diuretics (5%), ACEI (3.6%), and three-or-more-drug SPCs (2.8%). Among two-drug SPCs, amlodipine/atenolol (9.8%) was the most preferred, followed by telmisartan/hydrochlorothiazide (4.1%) and amlodipine/telmisartan (3.8%). There were inter-state variations in the market share of antihypertensive drugs. In four states, two-drug SPCs accounted for approximately 40% of all antihypertensives sold (range 38%-42%). This was followed by BBs as the second most preferred drug class in two states (range 18%-19%), while CCBs were preferred in the other two states (range 16%-18%). In the fifth state, CCBs (25%) were most preferred, followed closely by BBs (21%). Amlodipine/atenolol was the most preferred molecule in two states, amlodipine in another two states and telmisartan in the fifth state. Conclusions: Despite changes in standard hypertension treatment guidelines, evidence from pharmacy sales data indicate variable treatment practices in the private health sector in India, with a preference for beta blockers. This study highlights the need to improve hypertension care quality through private sector engagement strategies including sensitisation, regular training programmes and possibly provider incentives for evidence-based practice.