India needs to address non-communicable disease crisis

Non-communicable diseases (NCDs) are the leading causes of death and disease burden worldwide. Each year, 38 million people die of NCDs, of which about 75 per cent are in low and middle income countries. India's weak healthcare system is vulnerable to this growing burden. The economic and social ramifications of growing NCDs are dire. Unless dealt with on a war footing, involving a wide range of stakeholders involved in mitigation of NCDs, it has the potential to wreak havoc on Indian healthcare.

An NCD is a medical condition or disease which is non-infectious and non-transmissible among people. The most common NCDs are diabetes, respiratory diseases, cancer and cardiovascular diseases which account for 82 per cent of all NCD deaths worldwide. In India, 53 per cent of deaths take place due to NCDs. Studies show India as the leading country in premature death due to NCDs resulting in "highest loss in potentially productive years of life".

In India, 40 per cent of all hospital stays and 35 per cent of OPD visits are due to NCDs. The economic burden of NCDs is tremendous. EPIC model followed by WHO estimates a staggering $4.58 trillion loss to India from 2012 to 2030 due to NCDs. Such an estimate pales in front of the meagre amount government allocates for health. While there has been a 14 per cent increase in Budget for health this year, owing to earlier slashes, it is lesser in real terms than 2014-15 budgetary allocation.

Disconcerting diseases

There is enough evidence to point the alarming situation that major NCDs pose. Diabetes is one such example. Deaths due to diabetes in India doubled in 20 years from 1990 to 2010. The International Diabetes Federation estimates that about 33 per cent of diabetics are undiagnosed. ICMR INDIAB has pegged the number of pre-diabetics and diabetics at 139.6 million. This is a worrying number. Compounded with facts from a study in Chennai, which showed that only 12 per cent of people were aware that increased physical activity could help prevent diabetes, puts the country poised to be "diabetic capital of the world" in a precarious condition.

All the major NCDs including Cardio Vascular Disorders, the major "killer NCD", present a similar picture like diabetes. Mental health disorders also contribute to NCDs and present a sorry picture in India where there is only one psychiatrist per half a million people and one psychiatric nurse per two million people (as in 2005).

The first step in tackling NCDs is to have extensive research in public health. Understanding patterns of these NCDs, the prevalence, the causes, and with respect to Indian population is lacking. Indian Council of Medical Research, at least in undertaking the ICMR INDIAB (India Diabetes) study in recent time has plugged some gaps in literature but an abysmal 2.9% of health budget allocation for research this year does not bode well for the future of such studies.

The multitude programmes

There are several national health programmes targeting NCDs like National Tobaccco Control Programme (2007) implemented in 42 districts in 21 states, national programme for prevention and control of cancer, diabetes, CVD, stroke (NPCDCS) initiated in 2008 and slated to cover 100 districts, National Mental health programme (2003) implemented in 123 districts. Among other things, limited scale of implementation of these programmes has failed to make a dent in rising NCD numbers.

If these programmes are to become successful, independent evaluation of them is required with corrective measures based on their response and newer challenges. NCDs cannot be seen in isolation. Called as "diseases of prosperity", non-health sectors like agriculture, urban development, education and trade have a role to play in reduction of NCDs. Major determinants of NCDs include poverty, social inequality, illiteracy and poor health infrastructure all of which are mainstream challenges that plague India.

Looking for a resolve

The 66th United Nations General Assembly declared the importance of curbing NCDs. Besides, WHO came up with the "NCD action plan 2020" which fixes the primary role and responsibility of governments to work towards containing this alarmingly growing burden. WHO oversees measures to tackle NCDs under "global coordination mechanisms on NCDs" and has identified most cost effective measures of control of tobacco consumption and reduced salt consumption as first line of defence. In the second line are active lifestyle, healthy diets, prevention and screening and at a difficult to attain third is universal healthcare.

The risk factors for NCDs, among others, include tobacco use, harmful use of alcohol, lack of physical activity and a poor diet, all of which again are modifiable and, hence, should be the target of health policymakers. It has been suggested that addressing these four factors could contribute to a 40-50 per cent reduction in NCD deaths. The disinterest of the government in addressing the first line of defence is reflected in the examples of leaving out of tax net "beedis" and sugar-sweetened beverages.

Higher investment in strong healthcare foundation and early screening is essential in preventing NCDs. Screening for hypertension, HPV vaccination for cervical cancer, tobacco prevention and interventions in mental health diseases has shown good return of investment and those models needs to be practiced widely.

Reducing "out-of-pocket" expenditure which pushes hundreds of thousands of Indians to below poverty line each year is a major challenge for the healthcare industry. The treatment of NCDs, alarmingly, is almost double that of other diseases. Universal healthcare, the ideal measure against NCDs, and which has been promised by the successive governments remain elusive. While such a transformative change might take time, there is lot that health policymakers in the central and state governments can do to curb the rising NCD menace.