The Need for Risk Stratification in India’s Healthcare

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The United Nations recently called for its member states to show increased commitment to building sustainable and inclusive societies through the implementation of seventeen Sustainable Development Goals (SDGs). The third goal is to “ensure healthy lives and promote well-being for all at all ages” by reducing premature mortality from non-communicable diseases. To meet this goal, healthcare providers, especially in emerging markets, must find innovative responses. India is a strong case study for demonstrating the immense challenges that healthcare providers face as well as possible solutions.

Non-communicable diseases such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes are associated with a specific set of risk factors, including high blood pressure, high blood cholesterol, smoking, obesity, diabetes, and physical inactivity. As the medical community developed a clearer understanding of these risk factors, organizations such as the U.S. Preventive Services Task Force[1] and the U.K.’s National Institute for Health and Care Excellence[2] provided stakeholders with standardized guidelines on public health, clinical interventions, and medical technologies.

These standardized recommendations, even though medically pertinent, were hugely challenging for emerging economies like India to implement, given their complex operational protocols and high costs. To ease implementation, the World Health Organization (WHO)’s STEPS Manual grouped risk factors in three levels that could be implemented based on the availability of resources. For example, it called for determining the cardiovascular risk profile of an individual through non-invasive indicators (those that do not require blood samples), such as age, gender, and smoking status, among others, in order to determine a patient’s “riskiness” before checking a blood profile. Such risk stratification allows healthcare providers to adopt a population-based approach even with limited healthcare resources.

As a healthcare entrepreneur from India, I see enormous opportunity for establishing and scaling up an inclusive model of healthcare delivery. Healthcare service delivery going forward should prioritize community wellness and population health rather than individual health and disease management. This is not currently the case in India.

Primary healthcare in rural India in “well-performing” government managed primary health centers translates to 200 to 250 patients per day who are seen by a single doctor in less than four hours, translating to less than a minute per patient. These same doctors then return to their private practices to serve people within the same geographical area. There is a significant change in the quality of care, with better patient-physician interaction and better access to diagnostic facilities and medicines, though with higher costs for patients. Over decades, this has resulted in the private sector providing over 80 percent of India’s healthcare services. As India performs better on indicators such as average life expectancy it is only natural for the country to brace itself for the rising chronic disease burden that comes with increased life expectancy.

To face this challenge, a small number of healthcare providers have implemented technology-enabled risk-stratification for rural populations. One such provider is a social enterprise in South India, SughaVazhvu Healthcare, which I founded. It provides basic primary healthcare services to rural populations through a network of clinics.

In SughaVazhvu we developed a simple, mobile phone based Rapid Risk Assessment (RRA) tool to understand the underlying health risks for the population in our area, particularly for chronic conditions such as diabetes and hypertension.[3] RRA uses non-invasive risk factors such as age, gender, tobacco consumption, body mass index, waist-hip ratio, personal history of diabetes and/or hypertension, and blood pressure to determine whether an individual is at risk of having cardiovascular disease.[4]

In one of SughaVazhvu’s RRA screenings of over 3,000 adults, individuals that scored high on multiple risk factors were recommended to have blood work done at a health facility. Of the small percentage that followed through with the confirmatory diagnosis, 7.3 percent were found to have diabetes, 16.6 percent hypertension, and 11 percent hypercholesterolemia.[5] This represents a cost-effective way of identifying affected individuals in need of treatment.

Two key challenges that SughaVazhvu and similar organizations are facing in this approach are (a) scaling up these community-based risk assessment interventions and (b) managing diagnosed individuals’ compliance with a drug regimen and behavior change (lifestyle and diet modification). Government participation in these programs and widespread adoption of such models across the private sector can help address these challenges. The first step toward understanding risk and stratifying populations is implementing cost-effective, technology-enabled screening interventions on a mass scale.

As India commits itself to the SDGs and works toward providing universal healthcare, we need to realign healthcare stakeholders’ roles and incentives. A critical step, especially for non-communicable diseases, will be to move away from fee-for-service to health-outcome based models. A data-driven understanding of a community’s underlying risk for chronic diseases should inform healthcare priorities. Risk stratification through evidence-based screening tools is the most cost-effective and efficient way to address healthcare needs, including chronic diseases, across an evolving global healthcare landscape.

About the Author

Zeena Johar obtained her PhD from ETH Zurich in Drug Discovery in 2007 and moved to India as an entrepreneur. As the founder of SughaVazhvu Healthcare, Zeena scaled up the enterprise to serve over 75,000 patient visits. Zeena recently completed the Leadership Management Program at the Harvard Business School. Zeena was recognized as an Ashoka Fellow 2013, Aspen Fellow 2014, and Yale World Fellow 2015.

[1] U.S. Preventive Services Task Force, “About the USPSTF,” 2015, retrieved November 13, 2015, from

[2] National Institute for Health and Care Excellence, “Who we are,” 2015,

[3] The RRA followed the WHO’s STEPS, the Cambridge Risk Score, and the Indian Diabetes Risk Score.

[4] It also captures basic household information, such as number of family members, and age and gender profile of the family.

[5] Brookings Institution, “Enhancing Care Management for Diabetes Patients in Rural Communities,” 2015,–sughavazhvu-final.pdf.


Edited by Julie Bodenmann, Senior Editor for Articles and Sarah Gerstein, Editor for Articles.


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