Response to “Why is Preventive Health Care Not Picking Up in India?”

Dear Editor, This manuscript offers a timely and thought-provoking perspective on preventive health care, addressing a critically important yet often underexplored dimension of public health systems.1 However, it can be improved further by addressing the following points: In my opinion the manuscript would benefit from a more balanced framing of preventive care, recognizing that it is not solely an individual responsibility. While the current narrative emphasizes limited participation in check-ups, it would be important to highlight that preventive health care is fundamentally shaped by health system design. Screening uptake is influenced by the availability and functionality of primary care teams, continuity of care, referral pathways, affordability, trust in public systems, and population-level health literacy, as also emphasized in Indian NCD care models.2 In the Indian context, the discussion may be strengthened by incorporating the role of Ayushman Arogya Mandirs (Health and Wellness Centres) under Comprehensive Primary Health Care. These centres provide an existing policy and service delivery platform for operationalizing prevention through population-based screening, risk assessment, lifestyle counseling, early diagnosis, and long-term follow-up. The National Programme for Non-Communicable Diseases already envisage screening for individuals aged 30 years and above, along with continuity of care and access to medicines for chronic conditions.3 The argument may also be reframed from an “awareness gap” to an “implementation gap.” The more critical question is not only why individuals do not seek screening, but why the health system often fails to translate screening into confirmed diagnosis, treatment initiation, adherence, and sustained risk reduction. Evidence from community-based screening programmes in India suggests that tools like CBAC can identify high-risk individuals, but linkage to diagnosis and care remains a key bottleneck.4 Further, the discussion on prevention would benefit from a deeper engagement with the commercial determinants of health. While briefly mentioned, this could be expanded to include the growing influence of ultra-processed foods, tobacco, alcohol, and sedentary lifestyles, which undermine prevention efforts.4 Community engagement and structural interventions are essential to address these determinants and improve behaviour change outcomes.5 The section on health financing could be expanded to reflect those preventive services, being largely outpatient-based, often receive inadequate financial protection. Despite increasing investments, gaps remain in prioritization, budgeting, and accountability for preventive care within health systems.2 To enhance policy relevance, the manuscript may incorporate WHO-recommended NCD “best buys,” which have demonstrated effectiveness in low- and middle-income countries, including tobacco control, salt reduction, alcohol regulation, and management of hypertension and diabetes.6 While quaternary prevention is mentioned, it could be more critically applied by addressing the risks of over-screening and commercialization of preventive care. Corporate-driven screening packages may lead to unnecessary investigations, false positives, patient anxiety, and increased out-of-pocket expenditure, underscoring the need for evidence-based screening frameworks.6 An equity perspective would also be important to incorporate, particularly in identifying populations that are systematically underserved, such as women, informal workers, rural and tribal communities, migrants, the elderly, and individuals with low digital literacy. Without deliberate targeting, preventive strategies risk widening existing inequities.5 In addition, preventive care should not be presented as doctor-centric alone. The role of frontline workers, including ASHAs, ANMs, and Community Health Officers, should be emphasized. Evidence shows that ASHAs, along with personal from nonhealth sector, are willing and capable of participating in NCD screening and prevention, although they require training, supportive supervision, and strong referral linkages.7 Finally, the conclusion could be strengthened by proposing measurable and monitorable indicators, such as annual NCD risk assessment coverage among individuals aged above 30 years, control rates for hypertension and diabetes, referral completion rates, follow-up adherence, continuity of medication, coverage of tobacco cessation counseling, cervical cancer screening uptake, and inclusion of preventive counseling within insurance reimbursement frameworks. Such indicators would enhance the operational clarity and implementation relevance of the manuscript.8 Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.