In the outpatient pharmacy of a district hospital in Guntur, a patient with atrial fibrillation collects a month's supply of warfarin at no charge. The medicine is part of India's free drugs scheme, a program intended to reduce financial barriers to essential care. But the same patient will not find a machine to measure her INR—the blood test that determines whether the dose is safe—anywhere in the clinic. She will need to travel to the nearest town with a laboratory, wait half a day, and hope the result arrives before the next dose is due.

This mismatch between drug availability and diagnostic capacity is not a local glitch. Across Andhra Pradesh, public hospitals stock anticoagulants, but INR monitoring equipment is scarce at the primary-care level. Cardiologists and public-health researchers describe it as an oversight in planning—one that turns a lifesaving drug into a gamble. Dr. K. Srinivas, a cardiologist at a tertiary hospital in Visakhapatnam, puts it bluntly: “Stocking warfarin without monitoring is incomplete care. You are giving patients a drug that can kill them if you cannot check the effect.”

Warfarin Is Stockpiled, but Clinics Lack INR Machines

India's National List of Essential Medicines includes warfarin, and state procurement systems in Andhra Pradesh have ensured that district hospitals and many community health centres maintain a steady supply. The logic is straightforward: atrial fibrillation is common, stroke risk is high, and warfarin is cheap—roughly 50 paise per tablet. Yet the same logic has not extended to the diagnostic infrastructure needed to use the drug safely.

INR monitoring requires either a central laboratory with a coagulation analyzer or a point-of-care handheld coagulometer. In Andhra Pradesh's rural areas, central labs are concentrated in district headquarters, leaving primary health centres (PHCs) without access. A 2023 survey of 45 PHCs in three districts found that none had a functioning coagulometer. Most referred patients to the district hospital, a journey that could take two hours each way.

Dr. Meera Nair, a public-health researcher at the Indian Institute of Public Health in Hyderabad, led a retrospective audit of bleeding events in four district hospitals. “We found that 40% of admissions for major bleeding in patients on warfarin were likely related to supratherapeutic INR,” she says. “In many cases, the patient had not had a test in over a month. The drug was still being dispensed.” The audit, presented at a state-level cardiology meeting in early 2024, has not yet led to a change in procurement policy.

The problem is not unique to Andhra Pradesh. Similar gaps have been documented in other Indian states, but the scale in Andhra Pradesh is striking because the state has a relatively well-functioning drug distribution system. “The irony is that the supply chain works,” says Dr. Srinivas. “They can track every strip of warfarin. But they do not track whether the patient is bleeding or clotting.”

The INR Gap: Why It Matters for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and its prevalence is rising in India as the population ages. Without anticoagulation, AF roughly quintuples the risk of ischemic stroke. Warfarin, when kept within the therapeutic range—an INR of 2.0 to 3.0—reduces that risk by about two-thirds. Outside that range, the protective effect diminishes and the risk of bleeding climbs steeply.

Subtherapeutic INR leaves a patient unprotected. Supratherapeutic INR can cause intracranial or gastrointestinal bleeding, often requiring hospitalisation. A 2023 study in the Journal of the Indian College of Cardiology found that among AF patients in rural Andhra Pradesh who were prescribed warfarin, only 12% had an INR within range at their most recent test. The rest were either under- or over-anticoagulated, with nearly a quarter having an INR above 4.0.

Dr. Nair's audit corroborates this. Of 210 bleeding admissions she reviewed, 84 were directly attributed to warfarin. “Most of these patients had not had an INR check in the preceding two weeks,” she says. “Some had not been tested since starting the drug months earlier.” The consequences are not just clinical but economic: a bleed admission costs a district hospital roughly 15,000 to 20,000 rupees, many times the annual cost of INR monitoring.

The evidence from high-income countries is clear: anticoagulation clinics that maintain tight INR control reduce both stroke and bleeding rates. But in Andhra Pradesh, such clinics are rare. A few tertiary centres run dedicated anticoagulation services, but they cover only a fraction of the patients who need them. The distance between evidence and practice is substantial.

Free Drugs, Missing Tests: The Policy Disconnect

India's free medicines scheme, launched under the National Health Mission, has expanded access to essential drugs dramatically. Anticoagulants are on the list, and procurement volumes have risen year on year. Yet point-of-care INR devices—simple handheld meters that cost roughly 30,000 rupees each—are not on any state procurement list. The result is a system that provides the drug but not the means to use it safely.

A 2024 correspondence in The Lancet described this as “incomplete therapeutics,” arguing that stocking drugs without diagnostics is a waste of resources and a risk to patients. The authors, a group of Indian and international clinicians, called for a bundled approach: any clinic that dispenses warfarin should have access to INR testing. The comment drew attention but has not yet influenced policy.

State health budgets in Andhra Pradesh are tight, and officials often prioritise drugs over devices. A senior health administrator, speaking on condition of anonymity, explained: “Drugs are consumables. You buy them, you use them. Devices need maintenance, training, calibration. It is a different kind of investment.” The WHO's rehabilitation indicators, which focus on functioning and quality of life, do not capture this monitoring gap, leaving it invisible in global health metrics.

The disconnect extends to training. Nurses and pharmacists at PHCs are trained to dispense warfarin and counsel patients on diet, but they are not trained to adjust doses based on INR results. Even if a machine were available, the clinical pathway for dose adjustment is often unclear. A 2022 study in Guntur district found that fewer than 10% of PHC doctors felt confident adjusting warfarin doses.

Telehealth and Task-Sharing: Patchy Solutions Emerge

In response to the monitoring gap, a few pilot projects have begun testing alternative models. One of the most promising is in Guntur district, where a team from the Indian Institute of Public Health has trained community health workers—known as ASHAs (Accredited Social Health Activists)—to perform INR testing using handheld coagulometers. The workers travel to patients' homes, perform a fingerstick test, and transmit the result via WhatsApp to a central physician who recommends a dose adjustment.

Early data from the pilot, presented at a national conference in late 2024, show an 18% improvement in time-in-therapeutic-range compared with usual care. “The initial results are encouraging,” says Dr. Priya Reddy, the project lead. “But we have only 20 devices for a district of 4 million people. Scaling up will require a major investment.” The devices themselves cost roughly 30,000 rupees each, and the test strips add another 150 rupees per test—a recurring cost that state budgets have not yet absorbed.

Similar logistics challenges have emerged in other contexts. A recent “secret shopper” study of telehealth sites prescribing GLP-1 agonists, reported by STAT, found wide variation in monitoring practices. In that case, the issue was follow-up labs; here, it is baseline and follow-up INR. The common thread is that remote care models often neglect the diagnostic component, relying instead on patient self-reporting or infrequent lab visits.

Task-sharing—shifting INR monitoring from doctors to nurses or community workers—has been advocated by the WHO for decades, but uptake in India has been slow. Resistance comes from both professional bodies and patients. Some doctors argue that dose adjustment requires medical judgment that cannot be delegated. Patients, meanwhile, may distrust a test performed by a non-physician. The pilot in Guntur has tried to address this by having the physician confirm each dose change via phone, but the model remains fragile.

Where Experts Disagree: Central Lab vs. Point-of-Care

Among the clinicians and researchers working on this problem, there is no consensus on the best path forward. The central debate is whether to invest in point-of-care (POC) devices for every PHC or to strengthen the existing central lab network. Each option has vocal proponents and credible evidence behind it.

Dr. Rajesh Patel, a cardiologist at a private hospital in Vijayawada, argues that central labs are more reliable. “POC devices drift over time. They need regular quality control, which is hard to maintain in a PHC. A central lab with a good coagulation analyzer and trained technicians gives you a result you can trust,” he says. He points to studies showing that POC INR values can differ from lab values by 0.5 or more, enough to change a dosing decision.

Dr. Anjali Gupta, a public-health physician who has worked in rural clinics for a decade, counters that perfect accuracy is not always necessary. “If the alternative is no test at all, then a POC device with 90% accuracy is a huge improvement,” she says. “We are losing patients to bleeding and stroke because we do not test at all. A cheap, imperfect test is better than none.” Her view is supported by a 2023 meta-analysis that found POC INR testing in low-resource settings improved time-in-range without increasing adverse events.

No national guideline has settled this debate. The Indian Council of Medical Research (ICMR) has not issued a recommendation on POC vs. lab INR testing in primary care. The result is a patchwork: some districts have bought a few devices through local initiatives; others rely entirely on central labs. The inconsistency reflects a deeper uncertainty about what a functioning INR system should look like in a low-resource setting.

A third group argues that the debate itself is a distraction. “The real question is not which technology, but how to create a system that ensures every patient gets a test when they need one,” says Dr. Nair. “That could be POC, it could be a courier service to a central lab, it could be a mobile van. We need to stop arguing about perfect and start implementing something.”

What a Working INR System Would Require

Building a reliable INR monitoring network in Andhra Pradesh would require several components that are currently missing. The first is district-level quality assurance for coagulometers. Even if POC devices are deployed, they need regular calibration and control testing. A single malfunctioning device can produce dangerous errors across an entire clinic's patient panel.

The second is training. Nurses and pharmacists need to be able not only to perform the test but also to interpret the result and adjust the dose according to a simple algorithm. Several validated dosing protocols exist, but they are not widely disseminated in Indian public health settings. A 2024 study found that a one-day training workshop improved dose-adjustment accuracy by 40% among PHC nurses, but the effect faded after three months without refresher sessions.

The third need is a referral network for unstable patients. Patients with INR above 4.0 or below 1.5 need urgent medical attention, often including vitamin K or fresh frozen plasma. PHCs cannot manage this alone. A clear referral pathway—with transport, communication, and a designated receiving facility—is essential. In the Guntur pilot, the community health worker calls a central physician, who then decides whether to refer. But the ambulance service is often delayed.

Finally, the system must be integrated with India's Ayushman Bharat Digital Mission, which aims to create a unified health ID for every citizen. An INR value linked to a patient's digital record could trigger automatic alerts for out-of-range results and facilitate remote monitoring. But the digital infrastructure in rural Andhra Pradesh is still patchy, with unreliable internet and low smartphone penetration among older patients.

The complexity of these requirements mirrors debates in other areas of medicine. The recent discussion around JAK and IL-23 inhibitor dosing for ulcerative colitis, reported by MedPage Today, highlights a similar tension: optimal dosing requires frequent monitoring and adjustment, but the logistics of doing so in routine practice are daunting. In both cases, the gap between clinical trial evidence and real-world implementation is wide.

From Stockpiles to Safer Care: A Realistic Roadmap

A realistic first step would be to focus on high-risk AF patients in district hospitals. These patients are already identified and often have a prescription for warfarin. Providing them with a POC INR test at each refill visit would be relatively simple and would capture the patients most likely to benefit. A 2024 cost-effectiveness analysis suggested that even a 10% reduction in stroke and bleeding events would offset the cost of the devices within two years.

Procuring 50 INR devices per district—roughly one per ten PHCs—would be a relatively small investment. At 30,000 rupees each, the total for Andhra Pradesh's 13 districts would be about 19.5 million rupees, or roughly 0.2% of the state health budget. Pairing the devices with a smartphone-based decision-support app could standardise dosing and reduce the need for specialist oversight. Early versions of such apps exist but have not been validated in Indian populations.

The outcomes to monitor would be simple: bleed and stroke rates among warfarin users. Currently, these data are not systematically collected. A registry of AF patients on anticoagulation, linked to hospital discharge data, would allow the state to track whether the investment is working. Without such data, the debate over POC vs. central lab will remain theoretical.

Dr. Srinivas is cautious but not pessimistic. “We have the drugs. We have the patients. What we lack is the will to connect the two with a simple test,” he says. “It is not a technical problem. It is a policy problem. And policy problems can be solved.” Whether Andhra Pradesh will take that step remains an open question—one that will be answered not in conference halls but in the clinics where patients wait for a test that could save their lives.

This article is for informational purposes only and does not constitute medical advice. Patients on anticoagulation should consult their healthcare provider for individualised monitoring and dosing.