Understanding Roadblocks to Heart Failure Care (UNLOCK-HF): A Convergent Parallel Mixed-Methods Study in Kerala

Objective: Heart failure (HF) causes substantial morbidity, premature mortality and escalating healthcare costs, with prevalence rising fastest in low- and middle-income countries. Although guideline-recommended care can reduce mortality, its uptake remains suboptimal. We aimed to explore the roadblocks to optimal HF care in Kerala, a state in India with a high cardiovascular disease burden. Methods: We conducted a convergent parallel mixed-methods study. We collected availability and price data of guideline-recommended HF medicines from 30 pharmacies (government-subsidised 6; private-retail 24) and diagnostics and interventional procedures from 4 private hospitals. Interviews (10 HF patients, 7 carers, 4 physicians and 4 policymakers) explored roadblocks to prevention, diagnosis and treatment. Results: Mean availability of HF medicines was 45% in government-subsidised pharmacies and 66% in private pharmacies. Mean availability of HF diagnostics and interventional procedures was 89% and 57% in private hospitals. The lowest paid worker in Kerala would spend on average 0.3 days' wages to purchase a monthly supply of HF medicines in the government-subsidised pharmacies, and all but two HF medicines were affordable. The same worker would on average spend 1.4 days' wages for medicines in the private-retail pharmacies, 0.9 days' wages for cardiologist consultations, 8.4 days' wages for diagnostics and 1387 days' wages for interventional procedures. Interviews revealed care fragmentation, limited integration of HF management within broader programs, and gaps in patient and provider awareness. Conclusions: We identified several roadblocks to optimal HF care at various levels of healthcare, mainly low availability, poor affordability and fragmented care. Addressing these roadblocks requires a multilevel coordinated effort among all health system actors to ensure equitable and effective HF care.