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Stroke Patient Care and Challenges

India has made great strides in the medical field, and our advanced healthcare and highly skilled doctors are at par with the best in the world. India is one of most popular medical tourist destinations in the world. Foreign Tourist Arrivals (FTAs) in India on medical visa during 2016 and 2017 were estimated at 4.27 lakh and 4.95 lakh respectively, a growth of 15.9 percent. 

AIIMS New Delhi, the front runner institute for advanced medical studies and health facilities, was set up in 1956. Since then, 24 more such institutes have been added. As of June 2022, 19 Institutes are operating and 5 more are expected to become operational by 2025. However, we are a country catering to 1.38 billion people, and challenges exist in last-mile delivery. 

As per the 2019, World Health Organization (WHO) records, there is one doctor for every 10,189 people globally [PA1] while the WHO recommended ratio is 1:1000. Additionally, we face the challenge of the “dual disease burden”, or the prevalence of communicable diseases and a spike in non-communicable diseases (NCDs), or “lifestyle” diseases like diabetes, stroke, hypertension, kidney, liver and heart diseases. Nearly 50 percent of spending on in-patient beds goes for lifestyle diseases, as pointed out in an India Brand Equity Foundation (IBEF) report, that this has increased the demand for specialised care.

NCDs impact health, work productivity and economic growth. Given the propensity of COVID-19 storming NCD patients with low immunity, improving outcomes is imperative. Moreover, the 2030 Agenda for Sustainable Development adopted by the United Nations too recognizes the threat of NCDs to sustainable development and proposes to reduce premature mortality from NCDs by one-third by 2030[PA2]  (SDG target 3.4).

As per the WHO – NCD India profile – 2018, NCDs are estimated to account for 63% of all deaths in country. India accounted for 6.9 lakh deaths with 11.7 lakh incident cases of stroke as per “The Global Burden of Disease Study 1990-2019″. As per India Health of Nation’s States Report-2017, Stroke, a major NCD, is responsible for 3.5% of Disability Adjusted Life Year (DALY).  It is the fifth leading cause of disease burden in India as per the India Health of the Nations States Report by ICMR, 2017.  One in six people carry the risk of facing stroke. According to a Lancet study “Facing the Stroke burden worldwide, 2021”, 70% of strokes and 87% of both stroke-related deaths and DALYs occur in low-income and middle-income countries (LMICs).

The most common type of stroke is Ischemic Stroke, accounting for almost 87% of all strokes in India and is caused by a clot or other blockage within an artery in the brain. The other 13 percent strokes are hemorrhagic strokes caused by bleeding of an aneurysm in the brain artery. The incidence of stroke may create lifelong disability for the patient, weakens resources and societies, dissipates potential, and adds to the caregiver burden. However, it is crucial to note that in select cases, stroke can be treated efficiently through intravenous thrombolysis and mechanical thrombectomy (MT) with good chances of recovery. Timely treatment is crucial in stroke as it kills about 2 million brain cells in under a minute. Complications can vary according to the stroke type and if you are able to successfully receive treatment. Even a blockage in a small blood vessel may lead to paralysis, speech issues, visual impairment, losing control of bladder and bowel movement, coma or loss of life. Until recently, all treatments were done by open surgery. But currently, Mechanical Thrombectomy (MT), performed under guidance at catheterization labs (Cath labs), within 4.5 hours of a stroke incidence provides favorable clinical outcomes (Tawir & Muir, 2017).

The rising cases of stroke and the recent pandemic upheaval have demonstrated the need for improved healthcare delivery. Dealing with the challenge involves both increasing awareness to prevent such incidences, and also improving infrastructure. The government is building awareness for healthy living with various programs like Fit India, Yoga Day Celebrations, No Tobacco Day, and so on. Maintaining a healthy lifestyle, eschewing smoking and alcohol, monitoring of blood pressure and diabetes, including physical activities in daily routines, and reducing sodium in diet, are important to minimize risk factors.

Infrastructure needs to be improved as well. With only 2,300 Neurologists and 1,800 Neurosurgeons, and only 1400 Cath labs, many patients find it hard to access appropriate healthcare in time. Resources need to be allocated for primary prevention, rehab centres, speech therapy centres, family support for taking care of ill patients, increased Cath labs & diagnostic centres, and increased surveillance of diseases. Silos need to be broken in healthcare so that doctors from various streams are able to share a patient’s history. The National Digital Health Mission launched in 2020 will integrate healthcare and link practitioners with patients digitally by giving them access to real-time health records.

Indians have been the sixth biggest private spenders on health among low-middle income nations (Castor & Mohanty, 2018). Nearly 70% of healthcare is managed by the private sector leaving only 30% managed by the public sector. Public Private Partnerships can increase density of care, help in creation of more Cath labs, and also reduce costs for patients in the long run. A Hub and Spoke model works very well in better eco-system creation.

The Ayushman Bharat Prime Minister Jan Arogya Yojana (PM-JAY) aims to provide access to free and affordable healthcare services to vulnerable populations. In the revised Health Benefit Package (HBP 2.2), MT has been included for stroke patients and around, 400 procedure rates have been revised.

Healthcare has been highlighted as a prominent area of focus in Budget 2022. A 137% increase in healthcare expenditure was announced in Budget 2021. The central and state governments’ budgeted expenditure on the health sector reached 2.1 percent of GDP in 2021-22, against 1.3 percent in the previous fiscal, according to the Economic Survey 2021-22. A new scheme, Pradhan Mantri Atmanirbhar Swasth Bharat Yojana was announced in March 2021, to spend Rs 64,180 crore over the next 6 years with a focus on three areas, viz, preventive care, curative and wellness. Since 2017, NITI Aayog is committed to establishing the Health Index as an annual systematic tool to improve outcomes in States and UTs.

This will give a comparative analysis of regional health outcomes, so that timely action to boost infrastructure can be taken. Greater penetration of Cath labs and training to nursing staff in remote areas will improve last mile delivery. People experiencing Stroke often suffer with disabilities and face mental health challenges consequently. Increased awareness on healthy living, access to timely and affordable healthcare, and rehab facilities will go a long way in alleviating some of the pain of stroke patients. Hopefully, the decision to raise the number of colleges and the increased Health outlay will help in better outcomes.

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