Dr. Shammy Rajan 1

HEALTH POLICY ANALYSISNon Communicable Diseases Policy of India –

National Programme for prevention and control of Cancer Diabetes Cardio vascular

diseases and Stroke

Dr. Shammy RajanAssistant Surgeon

Department of Health ServicesGovernment of Kerala

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Introduction

• India started various programmes to prevent and control different Non communicable diseases (NCDs) from 1970s onwards

• There was hardly any policy direction on prevention and control of NCDs and their risk factors

• Prevention and control of NCDs like Diabetes, Hypertension, Cardiovascular diseases etc were not addressed in any of the initial programmes

http//www.ijcm.org.inviewimage.aspimg=IndianJCommunityMed_2011_36_5_7_94703_b3

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http//www.ijcm.org.inviewimage.aspimg=IndianJCommunityMed_2011_36_5_7_94703_b3

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• WHO described NCDs as Cancer, Diabetes, Cardiovascular diseases and Respiratory diseases

http://www.who.int/mediacentre/factsheets/fs355/en/

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Background

• India is a large nation with rapid development and urbanization

• Population- 1.237 billion (World Bank,2012)• GDP per capita- 1489.24 USD (World

Bank,2012)• Public sector in health- 33.5% (NFHS-3)

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International context

• Third Epidemiologic Transition1

• In developing countries, the transition is causing the double burden of both infectious diseases and non- communicable diseases upon which the NCDs possess the major share.4

• The study conducted in Accra, the most urbanized and modern city of Ghana, gives the typical picture of relation between pace of development of a nation and the speed of epidemiological transition.2

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• A comparative study, which was done among four Latin American countries, shown similar scenario.3

• But it is a fact that cost-effective public health interventions are not reaching developing country populations who need them. Programs to deliver these interventions are too often patchy, low quality, inequitable, and short-lived.5

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• NCDs kill more than 36 million people each year.• Nearly 80% of NCD deaths - 29 million - occur in low- and middle-income

countries.• More than nine million of all deaths attributed to NCDs occur before the

age of 60; 90% of these "premature" deaths occurred in low- and middle-income countries.

• Cardiovascular diseases account for most NCD deaths, or 17.3 million people annually, followed by cancers (7.6 million), respiratory diseases (4.2 million), and diabetes (1.3 million).

• These four groups of diseases account for around 80% of all NCD deaths.• They share four risk factors: tobacco use, physical inactivity, the harmful

use of alcohol and unhealthy diets.http://www.who.int/mediacentre/factsheets/fs355/en/

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Indian Context• In India, diabetic patients will increase from 19 million in

1995 to 87 million by 20306

• 66.6% of all cause mortality will be due to Non Communicable Diseases (NCDs) by 20207

• The overall prevalence of diabetes, hypertension, Ischemic Heart Diseases (IHD) and Stroke is 62.47, 159.46, 37.00 and 1.54 respectively per 1000 population of India(2010)

http://www.pib.nic.in/newsite/erelease.aspx?relid=63087. • The total cancer cases are likely to go up from 979,786

cases in the year 2010 to 1,148,757 cases in the year 2020.8

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Government of India(GoI) started efforts to control NCDs from 1970s and supported states who came with individual programmes9

Legal measures taken by Government of India aiming at non communicable diseases

• Mental Health Act 1987• Tobacco control act 2003National Health Policy – 2002 mentioned high burden of

mortality due to NCDs and injuries but there was no clear directions on prevention and control

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• High level officials from the GoI and WHO met on March 11, 2005 at Chennai during the 3rd Madras Diabetes Research Foundation – University of Alabama National Seminar on “Epidemiology of Non-communicable diseases” to discuss about the health burden due to NCDs.

• They came with the idea of constituting a network of professionals with expertise in NCDs for capacity building, for conducting high class research in NCDs in India as well as to formulate health care policies for preventing NCD in India

• Thus INN was formedwww.ncd.in

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Actors

• NCD division under DGHS• State Governments• NRHM• World Bank• WHO• ICMR• AIIMS• PHFI• INN

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• World bank published reports on NCD burden of India and gave many policy recommendations

• ICMR, AIIMS, INN and PHFI conducted various studies on NCDs and published them

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Policy process

11th 5 year plan(2007-11) - strategies• To start a national program for prevention and

control of Diabetes, Cardio vascular disease and stroke

• Initial expenditure of 1250 crores• Annual expenditure of 500 crores

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A Steering Committee has been constituted to review and expedite the National Programme for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke in the Chairmanship of Director General of Health Services with following members:

• (i) Director General of Health Services Chairman • (ii) Dr. K. Srinath Reddy ,Director PHFI Co-Chairman • (iii) Shri Vineet Chawdhry,Joint Secretary, MOH&FW ,Member • (iv) Dr. R.N. Salhan, Addl. Director ,General, Dte.GHS , Member • (v) Dr. Jagdish Prasad, Addl.D.G, • Principal & M.S Sufdarjung Hospital ,Member • (vi) Dr. Bela Shah, Senior DDG(NCD), ICMR ,Member • (vii) Prof. Madhuri Behari, HOD, Neurology, AIIMS , Member • (viii) Dr. Ajay Ajmani, Sr. Specialist and HOD, Department of Endocrinology, RML

Hospital Member

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• (ix) Dr. V.K. Bahl, Prof. and HOD, Department of Cardiology, AIIMS Member • (x) Prof. A.K. Das, MS and Dean, JIPMER, Pondicherry Member • (xi) Dr. B.K. Tiwari, Adviser, Nutrition, Dte.GHS Member • (xii) Dr. Harshvardhan, HOD, Cardiology, RML Hospital Member • (xiii) Prof. A. Ramachandran, Director, Diabetes Research Centre, Chennai.

Member • (xiv) Dr. V.Mohan, Diabetes Research Centre, Chennai Member • (xv) Dr. Cherian Varghese, NPO, WHO Member • (xvi) Dr. Jerzy Leowski Regional Adviser, SEARO, WHO Member • (xvii) Dr. K. Anand , Associate Prof. Department of Community Medicine,

AIIMS Member • (xviii) Dr. Sudhir Gupta, CMO (NCD), Dte. GHS Member Secretary

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• They designed a programme called NPDCS• Piloted on January 2008• 10 states were covered

– Punjab– Rajasthan– Karnataka– Kerala– Tamil Nadu– Assam– Madhya Pradesh– Andhra Pradesh– Sikkim– Gujarat

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• On 2011 January, GoI introduced a programme called National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease and Stroke (NPCDCS) by incorporating Cancer into this programme

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POLICY CONTENT

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Objectives Strategies AchievementPrevent and control common NCDs through behavior and life style changes

Prevention through behavior change

Behavior change from childhood level as a part of early prevention.

Provide early diagnosis and management of common NCDs

Early Diagnosis Early diagnoses was planned to be done by screening all adult above 30 years of age

Build capacity at various levels of health care for prevention, diagnosis and treatment of common NCDs

Treatment Uninterrupted supply of medicines

Train human resource within the public health setup viz. doctors, paramedics and nursing staff to cope with the increasing burden of NCDs

Capacity building of human resource

Training to staff of different sectors.

Establish and develop capacity for palliative & rehabilitative care.

Surveillance, Monitoring & Evaluation

Supervision, monitoring and evaluation concurrently and periodically.

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IMPLEMENTATION PLAN• The programme was planned to be implemented

in 20,000 Sub-Centers and 700 Community Health Centers (CHCs) in 100 Districts across 15 States/UTs.

• During 2010-11, it was implemented in 6482 Sub- centers, 205 CHCs, across 30 districts in 21 states

• Extended to 100 districts by 2011-12

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BUDGET• Estimated total outlay of Rs. 1230.90 crores• Rs.499.38 crores for interventions on diabetes

and cardiovascular diseases & stroke• Rs.731.52 crores for cancer control• Cost Sharing: Centre – 80% and State- 20%• The allocations for various level of institutions

were mentioned under separate heads

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Monitoring and evaluation• National NCD cell does the over all monitoring

and evaluation• NCD cell at different levels have to supervise

and monitor the programme• Done through HMIS, Review meetings, Field

observations, surveillance, operational research and evaluation studies

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Current Situation

12th 5 year plan – key strategies• Health Promotion for healthy life styles that preclude

NCDs and their risk factors• Specific prevention strategies which reduce exposure

to risk factors• Early Diagnosis through periodic/opportunistic

screening of population and better diagnostic facilities• Infrastructure Development and facilities required for

management of NCDs

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• Human Resources and their capacity building for prevention and treatment of NCDs

• Establish emergency medical services with rapid referral systems to reduce disability and mortality due to NCDs

• Treatment and care of persons with NCDs including rehabilitation and palliative care

• Health Legislation and population based interventions through multi sectoral approach for prevention of NCDs

• Building evidence for action through surveillance, monitoring and research.

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Critique

As per anecdotal evidence;• Budget was allocated till 2012-13 financial year• No funding since 2013-14• During 2013-14, fund diverted from NPHCE• Proposed staff strength could not be achieved• Lack of good quality data• Infrastructure development was poor• No measures for evaluation

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• More emphasis on diagnosis and treatment• Prevention and control measures were

minimal• Poor referral system• Problem of cancer and stroke was not

addressed properly

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References1. Harper K, Armelagos G. The Changing Disease-Scape in the Third Epidemiological

Transition. Int J Environ Res Public Health. 2010 Feb;7(2):675–97. 2. Agyei-Mensah S, de-Graft Aikins A. Epidemiological Transition and the Double Burden

of Disease in Accra, Ghana. J Urban Health Bull N Y Acad Med. 2010 Sep;87(5):879–97.

3. Albala C, Vio F, Yáñez M. [Epidemiological transition in Latin America: a comparison of four countries]. Rev Médica Chile. 1997 Jun;125(6):719–27.

4. Amuna P, Zotor FB. Epidemiological and nutrition transition in developing countries: impact on human health and development. Proc Nutr Soc. 2008 Feb;67(1):82–90.

5. Victora CG, Hanson K, Bryce J, Vaughan JP. Achieving universal coverage with health interventions. The Lancet. 2004 Oct 29;364(9444):1541–8.

6. Duran A, Khot A. Strengthening the Health System to Better Confront Noncommunicable Diseases in India. Indian J Community Med Off Publ Indian Assoc Prev Soc Med. 2011 Dec;36(Suppl1):S32–S37.

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References7. Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of

chronic diseases in India. Lancet. 2005 Nov 12;366(9498):1744–9. 8. Takiar R, Nadayil D, Nandakumar A. Projections of number of cancer cases in India

(2010-2020) by cancer groups. Asian Pac J Cancer Prev APJCP. 2010;11(4):1045–9. 9. Srivastava RK, Bachani D. Burden of NCDs, Policies and Programme for

Prevention and Control of NCDs in India. Indian J Community Med Off Publ Indian Assoc Prev Soc Med. 2011 Dec;36(Suppl1):S7–S12.

10. http://data.worldbank.org/indicator/SP.POP.TOTL11. http://www.who.int/mediacentre/factsheets/fs355/en/12. http://www.pib.nic.in/newsite/erelease.aspx?relid=6308713. www.ncd.in14.http://planningcommission.nic.in/aboutus/committee/wrkgrp11/

wg11_comble.pdf15. http://mohfw.nic.in/index.php