Phfi Ncd Report Sep 2011

Chronic Non-Communicable Diseasesin India

Reversing the tide

September 2011

Sailesh Mohan K. Srinath Reddy D. Prabhakaran

Public Health Foundation of India (PHFI) is an autonomous

Public-Private Partnership (PPP) created with support from

the Ministry of Health and Family Welfare, Government of

India. It was launched in March 2006 by the Honourable

Prime Minister of India. It’s mandate is to strengthen

public health in India through professional education,

training, health systems strengthening, support for policy

development, health communication and advocacy.

(www.phfi.org)

PREFACE

The High Level Meeting on Non-Communicable Diseases (NCDs), convened

by the United Nations in September 2011, is a very welcome and overdue

response to the escalating global threat posed by a cluster of diseases

which is already the foremost cause of death and disability. Low and middle income

countries, which are even now the major contributors to these disease burdens, will

bear the brunt of the debilitating health and developmental consequences of these

expanding epidemics.

Health transition in India, the second most populous country, exemplifies the

mounting menace of NCDs. A case study of India, profiling the present and projected

disease burdens and risk factor trends as well as the evolving health system and

multi-sectoral responses to these challenges, becomes very relevant in the context

of the UN meeting.

The geographic spread, cultural diversity and varied pace of development across

different regions are reflected in a wide range of NCD profiles within the country at

present. Nevertheless, the direction of change in NCDs uniformly points towards a

rapidly rising burden everywhere. Increasingly, poor people are becoming vulnerable

victims of diseases which have diffused across all social classes with alarming speed.

A comprehensive response is, therefore, urgently required to reverse this rising

tide. Such a response has to synergistically combine a ‘population approach’ of

prevention and health promotion with the ‘individual approach’ of early detection

and cost-effective care of individuals at high risk. This requires both a robust health

system response and coordinated multi-sectoral actions on the many determinants

of NCDs which traditionally lie outside the domain of the health sector.

India is gearing up to meet this challenge, by strengthening existing health

programmes for the prevention and control of NCDs as well as initiating new

programmes for dealing with diseases which were previously not covered.

Political commitment, which led to the Indian Parliament unanimously enacting a

comprehensive legislation for tobacco control in April 2003, is now extending to

a resolve to provide a well planned response to the threat of NCDs. Even as the

recent spurt in the economic growth has accelerated the shift to NCDs, it is also making

more resources available to health and other social sectors. This is likely to be reflected

in higher financial allocations for NCD prevention and control in the 12th Five Year

National Plan which becomes operational in April 2012. At the same time, major national

health programmes are getting increasingly integrated for effective delivery through a

strengthened health system. The country’s move towards Universal Health Coverage

is also likely to provide much needed financial protection to persons with NCDs who

require clinical care, while enhancing the ability of primary health services to prevent

them. Clearly the challenges are huge but there is confidence that India can design and

deliver an effective response.

As the UN meets to provide a global thrust to counter a global threat, India’s battle

against NCDs becomes integrated into a worldwide campaign to protect people

everywhere from avertable early death and easily preventable disability. In this

publication, we profile India’s position in this growing global movement. We hope

this contributes not only to improved information sharing among countries but also

to increased international cooperation for collectively responding to the 21st century’s

greatest health threat.

K. Srinath Reddy President

Public Health Foundation of India

Overview

Rise in NCDs and their risk factors

Surging NCD burden

Role of socioeconomic transition in the rise of NCDs

Current initiatives for NCD prevention and control

Public health strategies to prevent and control NCDs:the way forward

CONTENTS

1311212537

LIST OF ABBREVIATIONS

ABC Airway Breathing Circulation

ANM Auxiliary Nurse Midwife

ATS Adult Tobacco Survey

BCC Behaviour Change Communication

BMI Body Mass Index

BP Blood Pressure

CARRS Center for cArdiometabolic Risk Reduction in South Asia

CHC Community Health Centre

CHD Coronary Heart Disease

CHW Community Health Worker

COPD Chronic Obstructive Pulmonary Disease

COTPA Cigarettes and Other Tobacco Products Act

CVD Cardio Vascular Disease

DALYs Disability Adjusted Life Years

DM Diabetes Mellitus

DVT Deep Vein Thrombosis

ECG Electrocardiogram

ECHO Echocardiogram

FCTC Framework Convention on Tobacco Control

GATS Global Adult Tobacco Survey

GYM Global Youth Meet

GYTS Global Youth Tobacco Survey

HDL High Density Lipoprotein

HRIDAY Health Related Information Dissemination Amongst Youth

HTN Hypertension

IC-HEALTH Initiative for Cardiovascular Health Research in Developing Countries

ICMR Indian Council of Medical Research

IDSP Integrated Disease Surveillance Project

IEC Information Education Communication

IGT Impaired Glucose Tolerance

IHD Ischemic Heart Disease

IPHS Indian Public Health Standards

LDL Low Density Lipoprotein

MoHFW Ministry of Health and Family Welfare

MPHW Multi Purpose Health Worker

NCCP National Cancer Control Programme

NCD Non-Communicable Disease

NCMH National Commission on Macro Economics and Health

NCRP National Cancer Registry Programme

NFHS National Family Health Survey

NGO Non-Governmental Organisation

NIE National Institute of Epidemiology

NMHP National Mental Health Programme

NPCB National Programme for Control of Blindness

NPDCS National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke

NPCDCS National Programme on Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke

NTCP National Tobacco Control Programme

OCP Oral Contraceptive Pill

PHC Primary Health Centre

PHFI Public Health Foundation of India

PPLL Potential Productive Life Lost (years)

PPP Public Private Partnership

RCC Regional Cancer Centre

RDA Recommended Daily Allowance

RGI Registrar General of India

RNTCP Revised National Tuberculosis Control Programme

SBP Systolic Blood Pressure

SC Sub-Centre

SRS Sample Registration System

SSIP Sentinel Surveillance System for Cardiovascular Disease Risk Factors in the Indian Industrial Population

TB Tuberculosis

TIA Transient Ischaemic Attack

TNHSP Tamil Nadu Health System Project

TORCH Toxoplasmosis Other Rubella Cytomegalovirus Herpes simplex virus infections

WC Waist Circumference

WHO World Health Organisation

WHS World Health Survey

Y4H Youth For Health

S E P T E M B E R 2011 1

As India completes 65 years of independence, there has been remarkable

progress in the health status of its population. However, over the past

few decades, the country has experienced major transitions that have

impacted on health. Profound changes have occurred in economic development,

nutritional status, fertility and mortality rates and, consequently, the disease profile

has undergone considerable change. Although substantial progress has been

achieved in controlling communicable diseases, they still contribute significantly to

the national disease burden. Declines in morbidity and mortality from communicable

diseases have been accompanied by a gradual shift to, and accelerated rise in the

prevalence of, chronic non-communicable diseases (NCDs) such as cardiovascular

disease (CVD), diabetes, chronic obstructive pulmonary disease (COPD), cancers,

mental health disorders and injuries.

Notably, NCDs not only disproportionately impact people at younger ages in India

compared to developed countries, causing premature loss of life and national

economic loss, but also increasingly afflict the poorer sections of society.

A comprehensive strategy for the prevention and control of NCDs must integrate

public health actions to minimize risk factor exposure at the level of the population

and reduce risk at the level of individuals at high risk. Such a combination of the

population approach and the high risk approach is synergistically complementary,

cost-effective, and sustainable; and provides the strategic basis for early, medium

and long term impact on NCDs in India.

This report examines the current status of NCDs and their risk factors, the policy

and programmatic responses so far and suggests the public health strategies that

can contribute to reversing their rising trend in India.

OVERVIEW

C H R O N I C N O N-C O m m u N I C A b l e D I s e A s e s I N I N D I A R E V E R S I N G T H E T I D E2

S E P T E M B E R 2011 3

Rise in NCDs and their risk factors

It is estimated that NCDs accounted for 53% of the total mortality and 44% of disability

adjusted life years (DALYs) lost in India, in 2005, with projections indicating a further rise

to 67% of total mortality by 2030 (Fig.1). CVD is the major contributor to this burden and

accounts for 52% of NCD-associated mortality and 29% of total mortality. CVD related deaths

are expected to rise from 2.7 million in 2004 to 4 million by 2030.1,2 Mental health disorders are

also major contributors to the rising NCD burden in India. At least 7% of the adult population

suffer from a serious mental illness, including schizophrenia and mood disorders. This burden

increases substantially if we consider alcohol use disorders and common mental conditions

such as anxiety.3

Figure 1: Cause specific mortality in India

Most NCDs have shared risk factors (tobacco use, unhealthy diet, physical inactivity, alcohol

use) and integrated interventions targeting these risks form the cornerstone of the effort

to prevent and control NCDs (Fig.2). Given that risk factors of today are indicative of future

diseases, information on risks is vital for surveillance as well as for monitoring and evaluating

the effectiveness of potential interventions. Information on the major NCD risk factors in India

that contribute the most to the associated disease burden is summarised in the following

section.

Source: Adapted from reference 1


Figure 2: Deaths caused by nine leading NCD risk factors in India (%)

Tobacco

Tobacco use is a leading cause of premature, NCD-associated death and disability, and a

growing public health challenge. Tobacco is used in myriad ways with bidis, cigarettes and

smokeless (chewing) forms being the most common. India is the second largest producer and

the third largest consumer of tobacco in the world and is home to nearly 275 million tobacco

users.4,5

Projections indicate that nearly 13% of all deaths in India are tobacco-related. Notably, 50% of

cancers among men, 20% of cancers among women and 90% of oral cancers are attributable

to tobacco use. Further, over 80% of COPD among men, 60% of heart diseases in those less

than 40 years of age and 53% of myocardial infarctions among urban men are also attributed

to tobacco use. In addition, smoking contributes to nearly half of tuberculosis deaths among

men.4-8

Tobacco use also entails huge economic costs. The cost of treating three major tobacco-related

diseases (cancer, heart disease and COPD) alone is colossal and in 2002-2003 was estimated

to be 308.3 billion rupees, which was substantially more than the revenue received by the

government from tobacco sales.4


S E P T E M B E R 2011 5

Source: Reference 6

Many small, sub-national studies have reported on tobacco use, but data from national

surveys are available only from the 1990s. The latest National Family Health Survey (NFHS-3

of 2005-2006) indicates that currently 57% men and 10.8% women use some form of tobacco.

Thirty three percent of men smoke and 37% chew while 1.4% women smoke and 8.4% chew.9

Compared to the NFHS-2 of 1998-1999 in which 47% men and 14% women used some form of

tobacco, there has been an increase among men, particularly at younger ages and in urban

areas.10 In addition, there are huge, interstate and socio-economic variations, with many states

having a prevalence of over 60% tobacco use, the poor using more tobacco and rural areas

having a higher prevalence than urban areas.4

Most recent national data from the Global Adult Tobacco Survey, 2010 [(GATS) Fig. 3] indicated

the overall prevalence of tobacco use to be 35%, with increases noted in women compared to

earlier surveys (48% in men and 20% in women). Furthermore, over half of all adults reported

being exposed to second-hand smoke, underlining the importance of further strengthening

and effectively implementing smoke-free polices currently mandated by the Cigarettes and

Other Tobacco Products Act (COTPA) throughout the country.5

Smoking Causes Nearly 1 Million Deaths

● The poor are disproportionately affected

● Over ½ of these deaths occur among illiterate adults

● 70% of these deaths are in the 30-69 year age group, which is the most economically productive segment of the population

Figure 3: High tobacco consumption in India



Disconcertingly, tobacco use is also increasing among the youth which portends a huge NCD

burden in the future. Findings of the Global Youth Tobacco Survey, 2002 (GYTS) among 13-15

year old school children indicated that 17.5% were current tobacco users. There were wide

interstate variations, with Nagaland having the highest (62.8%) and Goa the lowest (3.3%)

prevalence of current tobacco use.4 Another study reported higher tobacco use among sixth-

grade students in comparison to eighth-grade students, indicative of a shift in age of initiation

to the tobacco habit and its increasing use among youth.11

Overweight and obesity

Although tremendous progress has been made in reducing undernutrition, India currently

faces the twin burden of both under and over nutrition, underlining the need for nutritional

policies that promote not only adequate but appropriate nutrition.

Large national surveys provide an indication of the time trends, particularly among women.

The NFHS-3 reported that 35.6% women in reproductive age group (15-49 years) had a body

mass index (BMI) of <18.5 kg/m2 indicating undernutrition, a slight improvement over NFHS-2

(35.8%). In contrast, 12.6% were overweight and 2.8% obese, a marginal increase compared to

that in the NFHS-2. Among men, 8% were overweight and 1% obese.9,12 A time trend for men

cannot be determined as they were not assessed in NFHS-2. In general, women in urban areas

with higher educational and income levels were more likely to be overweight or obese.

S E P T E M B E R 2011 7

The highest rates of overweight and obesity have been observed in the epidemiologically

and nutritionally advanced states of Punjab, Kerala and Delhi, which, incidentally, also have

higher rates of NCD risk and disease burden.9,13 The Jaipur Heart Watch studies demonstrated

an increasing trend in overweight/obesity among urban men (21.1% in 1994 to 50.9% in 2005) as

well as in women (15.7% in 1994 to 57.7% in 2005).14 More worrying is the increasing trend of

overweight and obesity among schoolchildren in various urban areas, as indicated by different,

local sample studies.12,15 This foreshadows a huge, future increase in obesity-related NCDs,

particularly hypertension and diabetes.

Further, Indians have a lesser BMI than Caucasian populations and increase in body weight,

even within the ‘normal’ range of BMI, confers a higher risk of CVD and diabetes. At equivalent

bmI, they also have significantly higher levels of visceral obesity and higher percent of body fat

than Caucasians. based on these facts, lower bmI cut-off value for overweight (>23 kg/m2) and

obesity (>27.5 kg/m2) have been suggested for identification of individuals at risk.16,17

Given the increased propensity of Indians for central obesity, and its importance as a measure of

obesity and as a cardiometabolic risk factor, the optimal bmI cut-off values have been defined

by various studies in India. For identifying any two cardiometabolic risk factors (diabetes

mellitus, pre-diabetes, hypertension, hypertriglyceridemia, hypercholesterolemia, or low high-

density lipoprotein cholesterol) the optimal cut-off value has been determined by mohan et

al to be 23 kg/m2 in both genders, whereas that of waist circumference (WC) was reported to

be 87 cm for men and 82 cm for women.18 Another analysis by Snehalatha et al reported the

healthy BMI for an urban Indian to be 23 kg/m2, and cut-off values for WC to be 85 cm for men

and 80 cm for women. 19

Dietary change in India

Despite little discernable change in the per capita calorie consumption in India, notable

increases in edible oil and fat intake have been reported in both rural and urban areas. Oil

intake increased from 18 grams per person daily in 1990-1992 to 27 grams per person daily

in 2003-2005, while fat intake rose from 41 grams to 52 grams per person daily during the

same period (Table 1). Furthermore, high income groups are reported to consume 32% of their

energy intake from fats, while their low income counterparts consume only 17%, underlining a

socioeconomic differential. Although national data on individual fat and oil intake is limited,

aggregate consumption data indicates an increasing trend in edible oil consumption, which

has risen from 9.7 million tonnes in 2000-2001 to 14.3 million tonnes in 2007-2008, with a high

proportion of unhealthy oils high in saturated and transfats.1,20


Table 1. Dietary changes in India

1990-1992 1995-1997 2003-2005Calorie intake (kcal/person/day)

2320 2380 2360

Protein intake (grams/person/day)

56 58 56

Fat intake (grams/person/day)

41 46 52

Oil intake (grams/person/day)

18 21 27

Percent share of total dietary intakeCarbohydrate 75 73 71Protein 10 10 10Fat 16 17 20

1993 2003 2007Oil consumption (in million tonnes)

5.8 10.5 14.3


In contrast, fruit and vegetable intake which is protective for NCDs is very low compared to

World Health Organisation (WHO) recommended levels (5 or more servings daily or at least

400 grams/day), particularly among low income groups compared to richer groups. A recent

study from South India reported fruit and vegetable consumption to be 265 grams/day, which

was lower than the recommended level.1, 21,22 Data from seven states of India where the first

phase of the Integrated Disease Surveillance Project (IDSP) was conducted, indicated lower

than WHO recommended levels of fruit and vegetable intake. In Maharashtra, 76% of those

surveyed reported consuming less than 5 servings daily, while in Tamil Nadu this figure was

99%.23 In the milieu of rising prices of fruits and vegetables, this underlines the need for sound

agricultural and pricing policies to ensure affordability and adequate availability.

Changing Food Habits

● Increased intake of edible oil and fat, including unhealthy oils

● Low fruit and vegetable intake

● Increased consumption of processed foods

● High consumption of salt

S E P T E M B E R 2011 9

Population salt consumption, a strong determinant of high blood pressure and associated

CVD, is very high across different regions with the average intake ranging between 9-12

grams/day, with the intake being higher in urban compared to rural areas. This is very high

compared to the WHO recommended intake of 5 grams/day as well as the National Institute

of Nutrition’s recent Recommended Dietary Allowances (RDA) for Indians that recommends

an intake of 6 grams/day. Most salt in India is added in cooking and/or at table in contrast to

the developed world where processed foods contribute the most to overall population salt

intake.24,25 However, with rapidly increasing urbanisation, proliferation of multinational food

outlets/fast food centres, increasing availability of prepared foods, and increasing frequency

of eating out of home, processed foods are anticipated to become a major source of salt

intake, making it imperative to initiate appropriate preventive public health action.


Physical inactivity

Population-based data on physical inactivity levels are sparse in India. The Indian component

of the World Health Survey (WHS), the only national level survey thus far, found that 29% of

the adult population had inadequate physical activity levels. A quarter of men (24%) and one-

third of women (34%) had inadequate physical activity levels (defined as one to 149 minutes

of activity in the week before the survey). Physical inactivity was higher in urban than rural

people and increased in those aged 45 years or more with over half of them being inadequately

active.26

Given the rapid urbanisation, increased motorisation, mechanisation and sedentarism at

workplaces, further increases are likely, particularly among the working age groups, thus

predisposing this segment of society to premature NCDs.

S E P T E M B E R 2011 11

Surging NCD burden

Coronary heart disease and stroke

The prevalence of coronary heart disease (CHD) ranges from 6.6% to 12.7% in urban and 2.1%

to 4.3% in rural India, among those aged 20 years or older. Prevalence has increased almost

four times in rural areas and six times in urban areas over the last 40 years.27 It is estimated

that there are currently 30 million CHD patients, with 14 million residing in rural and 16 million

in urban areas. But these are likely underestimates given that epidemiological surveys do not

include those with asymptomatic CHD.27

The age-adjusted, stroke prevalence is reported to be between 334 and 424 per 1,000,00

population in urban India and between 244 and 262 per 1,000,00 population in rural India and

has increased in both, during the past few decades.28 Population-based stroke data are limited

and most estimates are largely from small hospital-based studies, making assessment of secular

trends difficult. The age-adjusted incidence rate of stroke in urban studies has increased from 13

per 1,000,00 persons per year in 1970 to 105 in 2001 and 145 in 2005, indicating an upward trend

which is in consonance with the increased burden of its major risk factors like hypertension

and smoking. In addition, the thirty-day case fatality rate is reported to be 41%, which is much

higher than that in developed countries (17% to 33%).29,30

In comparison to other countries, CVD in India is distinguished by earlier onset and premature

mortality, higher case fatality rate of CVD-related complications, and manifestation of

clinical disease at lower risk factor thresholds, particularly with overweight and obesity. CVD

disproportionately affects the young in India with 52% of deaths occurring under the age of 70

years compared to just 23% in Western countries.31

The most recent data from a rural setting which is in an advanced stage of the epidemiological

transition reveal that 60% and 40% of CHD deaths and 40% and 20% of stroke deaths, in men

and women respectively, occurred in those under 65 years, underlining how devastating CVD

is from a societal perspective.32 Consequently, the country suffers a very high loss in potential

productive years of life because of premature CVD deaths among those aged 35 to 64 years:

9.2 million years lost in 2000 and 17.9 million years expected to be lost in 2030 (Fig. 4).33


CVD and diabetes also entail a huge national economic burden (Fig. 5). The projected foregone

national income due to CVD and diabetes during the period 2005-2015, is estimated to be

more than $237 billion.35 In addition, it also leads to distress financing and huge amounts of

catastrophic expenditures. For instance, catastrophic expenditure among poor people who

suffered acute coronary syndrome in Kerala was as high as 92%.2

High blood pressure

India has a large number of hypertensives with projections indicating nearly a doubling from

118 million in 2000 to 213 million by 2025. Hypertension prevalence in adults is between 20%

and 40% in urban areas and 12% and 17% in rural areas.27 An earlier meta-analysis reported 25%

prevalence among urban adults and 10% among rural adults. 37

The Indian Council of Medical Research (ICMR) estimates that 16% of ischemic heart disease

(IHD), 21% of peripheral vascular disease, 24% of acute myocardial infarctions and 29% of strokes

in India could be attributable to high blood pressure. 38 National data are unavailable, but many

sub-national studies have reported increases in hypertension across the country over the past

two decades.37

Figure 4: Years of Potential Productive Life Lost (PPLL) in adults aged 35 to 64 years due to CVD selected countries (2000 and 2030)


South Africa

USA

Russia

China

India

Number (millions)

S E P T E M B E R 2011 13


Figure 5: Annual income loss from work absenteeism, care giving time and premature death in Indian households with an NCD suffering member, 2004

It is worth noting that between 1942 and 1997, the mean systolic blood pressure (SBP) has

increased from 120 mmHg to 130 mmHg, particularly among 40 to 49 year old urban men.39

Population time trends in national prevalence are unavailable but well conducted cross

sectional studies such as the Jaipur Heart Watch from Western India provide evidence of an

increase over time; this is likely to indicate the pattern of increase in the country as a whole.

During 1993-2005, a significant increase was observed both among men and women. Age-

adjusted prevalence increased in men from 29% to 45% and in women from 22% to 38%.14 Studies

from other regions also point to an increasing burden of hypertension.28,40

Furthermore, detection, management and control rates are below desired levels. Various

reports indicate that only about 30% of people with hypertension are detected, less than half

of those diagnosed take anti-hypertensives and only half of them have their blood pressure

treated and controlled.1 Notably, once hypertension-related CVD occurs, the use of evidence-

based, secondary prevention therapies is also low in primary and secondary care, leading to a

large and increasing burden of avoidable and premature mortality.41-43


Metabolic syndrome

Recent data indicate that one fourth to one third of the urban population in India has metabolic

syndrome (a cluster of risk factors which include abdominal obesity, high blood sugar, abnormal

blood fat levels or ratios, increased clotting tendency and markers of heightened inflammatory

activity). Of note, Indians have a higher prevalence of hypertriglyceridemia and abnormally

high levels of small dense LDL-cholesterol and low levels of HDL-cholesterol, placing them at

increased risk of CVD and diabetes.21,44

Diabetes

Diabetes prevalence has been increasing rapidly, with the country being labelled as the

‘diabetes capital’ of the world until recently. The escalation in the diabetes burden means

high healthcare costs for the individual besides contributing to foregone national income. In

2010, the annual median direct cost per diabetic individual was reported to be US$525, and the

annual total cost of diabetes care in India was estimated to be US $32 billion, underlining the

huge economic impact that NCDs such as diabetes have on households as well as the national

economy.48

Diabetes: Dire Warnings ● 51 million Indians have diabetes currently

● 87 million may have diabetes by 2025

● Current prevalence varies from 5% to 15% in urban and 2% to 5% in rural areas

● Between 9% and 30% of Indians have impaired glucose tolerance (IGT), a likely indicator of further future increases in the disease burden

● 0.1 million die due to diabetes annually

Moreover, diabetes-related complications are a major contributor to morbidity and mortality:

for instance, CHD prevalence is considerably higher among those with diabetes and those with

IGT (21.4% and 14.9%) compared to those without diabetes (9.1%). Similarly, the prevalence

of peripheral vascular disease is also higher among those with diabetes than among those

without diabetes (6.3% versus 2.7%). Microvascular complications such as diabetic retinopathy,

overt nephropathy and microalbuminuria affect 17.6%, 2.2% and 26.9% of Indians respectively.

Southern states have a higher prevalence compared to rest of India and recent data indicate

that in certain settings a reversal of the social gradient is occurring with those in lower social

classes experiencing an increasing burden.46,47 Well-designed repeat surveys in Chennai provide

evidence of an increasing trend, particularly in urban areas. The prevalence of diabetes increased

Source: Reference 45, 46, 47

S E P T E M B E R 2011 15

from 8.3% in 1989 to 11.6% in 1995, to 13.9% in 2000, to 14.3% in 2003, and to 18.6% in 2006. This

marked an increase of over 70%, with a downward shift in the age of onset of diabetes within a

relatively short time span.46,47,49,50

Cancer

The age-standardised rates are 96.4 per 1,00,000 in men and 88.2 per 1,00,000 in women.52

The most common cancers in men are those of the oral cavity, esophagus and lung. The chief

cancer sites in women are the cervix, breast and ovaries (apart from tobacco-related ones).

Data from the National Cancer Registry Programme (NCRP) show increasing trends between

1982 and 1990 for breast, gallbladder and thyroid cancers and non-Hodgkin’s lymphoma in

women and for the cancers of esophagus, prostrate, mouth and non-Hodgkin’s lymphoma

in men.53 Diagnosis and treatment are often delayed, with more than 75% of cancer patients

presenting and seeking care when already in advanced stages of the disease, thereby reducing

the likelihood of positive treatment outcomes.54

As previously mentioned, tobacco use is one of the main risk factors. Alcohol use also

contributes to a substantial proportion of head and neck cancers as well as stomach cancer. In

addition, dietary, reproductive and sexual practices account for 20% to 30% of cancers.54

Combating Cancer: The Case for Action ● 2.5 million people suffer from cancer

● About 8,00,000 new cases of cancer occur each year

● By 2016 10,00,000 new cases of cancer will occur each year

● Cancer deaths will increase from 7, 30,000 deaths currently to 1.5 million deaths by 2030

Source: Reference 1, 2, 51

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is more common in men (5%) than in women

(2.7%) aged 30 years and above, with the prevalence being higher among smokers. From

available data, it appears that there has not been much discernible change since the 1970s

when prevalence was reported to be 4.2% in men and 2.7% in women.55 However, most studies

are limited in size and scope, and national data on both prevalence and associated mortality are

not available, making inference concerning time trends difficult. The number of COPD patients

is estimated to increase from 1,30,00,000 in 1996 to 2,22,00,000 by 2016 with many likely to

require hospitalisation. This will have significant financial implications for individuals and the


healthcare system. Indoor air pollution from use of solid unclean cooking fuels (wood, dried

dung, crop residues) is a major contributor to the COPD burden, particularly among women

and children under 5 years who jointly receive the maximum exposures.55-57 Since access to

clean fuels (such as cooking gas) will take time for scale up in rural areas, efforts are being

made to develop and deploy safer cooking stoves which will reduce exposure to indoor smoke.

Mental health disorders

Mental health disorders have emerged as a major public health problem in India. Conditions

such as schizophrenia, mood disorders (depression and bipolar mood disorders) and mental

retardation account for 8.5% of the total burden of diseases. The National Commission on

macro economics and Health (NCmH) estimated that nearly 7% of the adult population suffer

from a serious mental disorder, with no considerable rural urban difference. The age group of

25-44 years is more vulnerable. Women had comparatively higher rates of mental disorders

than men.3 Recent estimates suggest that, neuropsychiatric conditions were the top cause of

DALYs lost in India in 2004. By 2030, unipolar depressive disorders are projected to be one of

the four leading causes of DALYs lost in India.1, 2

There are social and behavioural determinants of mental health disorders. The social

determinants include social gradients (in education, income, occupation), early life

experiences, stress, unemployment, lack of social support and social exclusion. The behavioural

determinants are alcoholism, drug addiction and smoking. mental health disorders affecting

the younger age groups lead to severe degree of loss of productivity and considerably decrease

the quality of life, with associated stigma.

Due to its far reaching impact, recently many strides are being made across the country and

globally, to recognize mental health disorders as important contributors to the disease burden.

They not only are independent risk factors for other chronic diseases such as CVD and diabetes

but are also a consequence of long term suffering from them.1 Other chronic diseases often

lead to reactive depression; while hostility, stress and depression are known to increase the

risk of CVD.

Road traffic accidents and injuries

Given the high levels of urbanisation, population growth and economic development, there

have been phenomenal increases in motorisation in India. An additional contributing factor to

this rise is the inadequacy of public transport systems. Automobile production has increased

prodigiously. The estimated annual mortality rate was 20.9 per 1,00,000 population for all ages

S E P T E M B E R 2011 17

in 2002, which is a likely underestimate

given the inadequate death registration

system in India.58 Currently, about 2.8

million people are hospitalised due to

road traffic accidents, a figure projected

to increase to 3.6 million hospitalisations

by 2015.59 It is anticipated that between

2004 and 2030, injury related deaths will

further increase by 30%.2 The majority

of victims are men, often belonging to

the poorer strata of society, and they

are usually pedestrians, motorcyclists

or bicyclists (Fig. 6). States with rapid and higher motorisation rates have greater numbers

of related injuries and deaths.59 Agricultural related injuries are also common, occurring

predominantly among men residing in rural areas, and belonging to the lower income group.59

Bringing Road Traffic Accidents and Injuries to a Halt ● The number of vehicles rose nearly 14 times from 5.1 million (1981) to 73 million

(2004) and continue to increase each year

● between 1991 and 2005, road traffic accident-related deaths have doubled (50,700 to 1,10,000) and injuries have quadrupled (1,09,100 to 4,65,282)

● Among the leading causes of death and disability in the productive age group, 15-44 years

Figure 6:

Road traffic accident deaths by type of vehicle (%)

Source: Reference 58



Disability

In India, about 1.8 % - 2.1% of the population suffer from disabilities, which include visual, hearing,

speech, locomotor and mental disabilities. Men have a slightly higher prevalence of disability

(2%) compared to women (1.5%). Three-quarters of those with disabilities reside in rural areas,

nearly half are literate but only a third are gainfully employed. Available data indicate that

locomotor disabilities are the most common, afflicting all age groups, while visual and hearing

disabilities are more frequently reported among the aged.61, 62 Disabled people are more likely

to be malnourished, impoverished, live in unsanitary conditions and have lower social status

as well as lesser access to the healthcare system. All these factors increase their risk of disease

and adverse health outcomes.63

Disabilities may arise from many diverse causes. birth asphyxia or birth trauma, due to difficult

or poorly assisted child birth is, for example, a cause of cerebral palsy (Table 2). Road traffic

accidents, burns and workplace related injuries also result in serious disabilities. NCDs such as

CVD, diabetes, cancers and injuries are also contributing causes for disability. Given the rising

trend of NCDs, the disease burden associated with disabilities is projected to rise further and

thus needs to be addressed through appropriate programmes and policies that encompass

both prevention as well as rehabilitation.

People with disabilities can live and actively participate in productive societal activities

when adequate rehabilitation services to maximise their functioning and to support their

independence are provided. This includes provision of assistive devices (wheelchairs,

prostheses, hearing aids), surgical correction, therapeutic services (physiotherapy, occupational

therapy, speech therapy), education in special and integrated learning institutions, vocational

training, job placement in local industries, and capacity building for self-employment. Further,

policies that promote disability friendly access to buildings, public transport and public spaces

are essential and can contribute considerably to enhancing the quality of life of those with

disabilities.

S E P T E M B E R 2011 19

Table 2. Developmental disabilities in children:some risk factors and causal associations

Diseases such as TORCH infections in mother

Developmental defects in brain due to gene abnormality

Poor nutrition and disturbed metabolism as in maternal diabetes

Before Birth

Exposure to radiation, harmful drugs

Severe forms of blood groups or Rh incompatibility

Disturbed circulation of the foetus due to maternal hypertension, toxaemia of pregnancy

Prolonged labour and compression of brain

Head injuries related to obstetric causes

Hypoxia (birth asphyxia) from premature separation of placenta

At BirthCardio respiratory problems in baby causing relative lack of oxygen to baby’s brain

Pre-maturity and susceptibility of brain to haemorrhage (bleed)

Metabolic disturbances and infections in the new born

Diseases such as meningitis, encephalitis, measles

Head injuries in early infancy and childhood

Poisoning or accidental ingestion of toxins

After BirthAnoxia from drowning, severe respiratory problems

Vascular accidents and intracranial bleeds associated with metabolic disturbances

Rarer causes such as brain tumours


S E P T E M B E R 2011 21

Role of socioeconomic transition in the rise of NCDs

India has experienced rapid urbanisation in recent years as a result of population growth

as well as an increased pace of economic development. This has been associated with

industrialisation, modernisation and increased utilisation of technology, with unplanned

expansion of cities into adjoining areas and increased within-country migration from rural to

urban areas. In addition, it has placed increased demands on existing urban infrastructure,

services and public spaces, leading to increases in the disease burden (including increased

susceptibility to NCD risks such as tobacco, alcohol, unhealthy diet and physical inactivity).

As people migrate from rural areas, they experience improvement in their standard of

living but also adverse lifestyle and environmental influences on diet and other behaviours

that predispose them to NCDs. Evidence of this is emerging as rural migrants are reportedly

reducing levels of physical activity, increasing intake of dietary fat and becoming more

obese and prone to diabetes.65 Further, reports also reveal the reversal of the social gradient

whereby the poor suffer increased vulnerability to NCD risks and disease, a situation similar to

that observed in developed countries that already have undergone health transition (Fig. 7).


Risk factors which are initially high among the higher socioeconomic classes percolate down

to lower classes gradually, and the lower classes then bear the brunt of the disease and risk

burden. Data from certain settings provide clear evidence for this reversal (Table 3).


Figure 7: NCD burden and intervention coverage amongdifferent social groups in India

(A-Burden of disease, B-Intervention coverage, Q1-Poorest quartile, Q4-Richest quartile)

Prev

alen

ce in

pop

ulat

ion

(%)

Cove

rage

in p

opul

atio

n (%

)

Angina Depression Diabetes Road Injury

Angina Depression Diabetes Road Injury

S E P T E M B E R 2011 23

Table 3. Cardiovascular risk factors by educational status inan Indian industrial population (%)

Risk Factor ES I ES II ES III ES IV P-value for Trend

Tobacco use

Men

Women

19.8

1.2

26.5

1.6

40.2

2.7

77.3

42.1

< 0.001

< 0.001Hypertension

Men

Women

27.2

15.3

29.9

18.4

28.6

23.8

32.6

34.7

0.05

< 0.001Overweight

Men

Women

37.0

39.3

33.1

37.4

30.4

41.5

9.1

22.9

< 0.001

< 0.001Diabetes

Men

Women

8.4

4.2

10.4

4.8

13.3

9.8

7.6

11.2

0.08

0.01

ES I: Post Graduate, ES II: Graduate, ES III: Secondary or High School, ES IV: Primary or Illiterate


In a large, multi-site, national study of the industrial population, tobacco use (56.6% versus

12.5%) and hypertension (33.8% versus 22.7%) were significantly higher in the low education

group than in the high education group. In contrast, those with high education and located

in highly urbanised areas had a lower prevalence of tobacco use, hypertension, overweight

and diabetes than those with low education.66 A recent survey in Kerala reported one of the

highest diabetes prevalence rates (14.6%) so far, in a rural setting.67 Even among the urban poor

in North India, high rates of obesity (14%), dyslipidaemia (27%) and diabetes (10.3%) have been

reported.68 Furthermore, a recent study from Chandigarh and Haryana found most CVD risk

factors to be similar among those residing in urban and rural areas, indicating the increased

vulnerability of the poor to CVD.69

A case-control study of myocardial infarction (heart attack), conducted in Delhi and Bangalore,

observed a higher risk in those with lower levels of education and income.70 This suggests

that the socio-economic gradient for NCDs progressively reverses as the epidemics advance,

making the poor most vulnerable both in terms of increased risk of acquiring disease and

lacking access to expensive clinical care.

S E P T E M B E R 2011 25

Current initiatives for NCD prevention and control

The healthcare system in India is in the process of being re-oriented to also address the

rising threat posed by NCDs, in addition to the delivery of programmes for infectious

diseases and reproductive health services. Clinical care of NCDs is also widely variable

in availability and quality with individuals belonging to higher echelons of society having

access to the best possible evidence based care in tertiary hospitals and the poor lacking

access to even basic care, resulting in their illnesses being either undetected or inadequately

treated leading to avoidable complications, premature mortality and disability.2 This disparity

is reflected in health sector allocations, as reflected in the ministry of Health and Family

Welfare’s (MoHFW) outlay for the 11th Five Year Plan of 2007-2012 (Table 4).1

Table 4. Proposed allocation for NCD programmes in the 11th Five Year Plan

Programme Proposed Outlay (Million INR)

Percent of Total Outlay

National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS)

12,500 5 %

National Trauma Care Programme 10,303 4%National Cancer Control Programme 20,000 8%All NCD Control Programmes * 66,586 28%Communicable Disease Control Programmes 1,72,641 72%Total 2,40,222 100%* includes national programmes on cancer, blindness, mental health, iodine deficiency disorders, oral health, deafness, medical rehabilitation, organ transplant, fluorosis, geriatrics, trauma, and the National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS)


Existing programmes for NCDs

The country has some existing national programmes for NCD prevention and control. These

include the National Cancer Control Programme (NCCP) initiated in 1975, the National Trauma

Control Programme, the National Programme for Control of Blindness (NPCB), the National

Mental Health Programme (NMHP), the National Tobacco Control Programme (NTCP), and

the recent National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular

Diseases and Stroke (NPCDCS). There is a proposal to merge the NCCP with NPCDCS.


In addition to tracking financial allocations, efforts around monitoring and evaluation of NCD

programmes are now planning to focus on health indicator/health outcome based monitoring

and enforcement of benchmarks for performance assessment.

National Cancer Control Programme

The National Cancer Control Programme was started in 1975. The cancer control components

are implemented through 25 Regional Cancer Centres (RCC) and 210 other institutions equipped

with radiotherapy facilities. Cancer care facilities are also available in a number of medical

colleges as well as in some private sector hospitals. The programme’s scope has recently been

expanded. Currently there are five schemes under the revised programme:

a) Recognition of new RCCs

b) Strengthening existing RCCs

c) Development of an oncology wing by providing enhanced grant-in-aid to government institutions (medical colleges and government hospitals)

d) Developing District Cancer Control Programmes by providing grant-in-aid, and

e) A decentralised NGO scheme by providing support to NGOs for information, education, and communication (IEC) activities related to cancer prevention and control.

In addition, the National Cancer Registry Programme (NCRP), started in 1982, has 13 population

based cancer registries which monitor cancer incidence and trends in the country.1

National Trauma Control Programme

The MoHFW is currently developing and implementing a national programme on trauma

control to address the growing number of road traffic injuries. It consists of four components:

a) Pre-hospital trauma care

b) Hospital care

c) Rehabilitation of the injured, and

d) Injury prevention.

A nodal cell has been proposed at the MoHFW to coordinate a registry, injury surveillance,

and to implement a comprehensive national trauma care system with state wide emergency

medical service and trauma care. The National Institute of Mental Health and Neurosciences,

bangalore, leads injury surveillance efforts, providing data and an evidence-base for the

national programme. A National Programme for Medical Emergencies Response is also being

developed.1

National Programme for Control of Blindness

The National Programme for Control of Blindness was launched in 1976 with the goal of

reducing the prevalence of blindness to 0.3% by 2020. The implementation of the programme

S E P T E M B E R 2011 27

was decentralised in 1994-1995 with formation of a District Health Society in each district of the

country. The major objectives of the programme are to:

a) Reduce the backlog of blindness cases through identification and treatment of the blind

b) Develop comprehensive eye care facilities in every district

c) Develop human resources for providing eye care services

d) Improve quality of service delivery

e) Secure participation of voluntary organisations/private practitioners in eye care, and

f) Enhance community awareness on eye care.

Rapid survey on avoidable blindness conducted under NPCB during 2006-2007 showed

reduction in the prevalence rate of blindness to 1% by 2006-2007.71

National Mental Health Programme

The National Mental Health Programme was initiated in 1983 to address the rising disease

burden of mental illness and the inadequacy of mental healthcare infrastructure (Box 1). It

aims to:

a) Ensure availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population

b) Encourage application of mental health knowledge in general healthcare and in social development

c) Promote community participation in the mental health services development and to stimulate efforts towards self-help in the community.72

Box 1. Potential Cost Effective Interventions for Mental Health Disorders

● Clinical interventions for mental health disorders (antipsychotic drugs for schizophrenia, antidepressant drugs for depression) covering at least 50% of those requiring them (Rs. 19,360 per DALY averted).

● Interventions for alcohol misuse including psychosocial treatment in primary care (Rs. 21,560 per DALY averted).

● Alcohol pricing policies aimed at increasing excise taxation or reducing untaxed consumption (Rs. 968 per DALY averted).

Source: Reference 2


National Tobacco Control Programme

The National Tobacco Control Programme was initiated in 2007-2008 on a pilot basis in 9

states and subsequently extended to 12 more states to implement anti-tobacco laws. The main

components of the NTCP are:

a) District tobacco control programme with a strong monitoring mechanism at the state/central level

b) IEC / mass media campaigns

c) Research and training

d) Capacity building of existing laboratories for testing tobacco products, and

e) Monitoring and evaluation, including conduct of Adult Tobacco Survey (ATS).

Existing health warnings for smoked and smokeless tobacco products

S E P T E M B E R 2011 29

The implementation of NTCP is accomplished through a state Tobacco Control Cell located

at the state Directorate of Health Services. The District Tobacco Control Units function under

the state cell, implementing training programmes in tobacco control for health professionals,

law enforcers and civil society organisations, conducting IEC activities, school based tobacco

control activities, monitoring of the implementation of existing tobacco control laws and

setting up of tobacco cessation clinics.73

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke

In 2007, a National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases

and Stroke (NPDCS) was launched on a pilot basis in ten states (Assam, Punjab, Rajasthan,

Karnataka, Tamil Nadu, Kerala, Andhra Pradesh, Madhya Pradesh, Sikkim and Gujarat). The

pilot programme’s objectives were to: assess the prevalence of risk factors for NCDs (diabetes,

CVD and stroke), reduce the risk factors for developing NCDs; and provide early diagnosis and

appropriate management. Recently, it has been renamed as the National Programme for

Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS).

The programme will be implemented through the primary healthcare system (in 20,000 sub-

centres (SCs) and 700 community health centres (CHCs) located in 100 districts of 15 states) and

will aim at: a) assessment of risk factors, early diagnosis and appropriate disease management

for high risk groups b) health promotion for the general population. The programme envisages

opportunistic screening at the primary point of contact in the village (SCs), CHCs, district and

tertiary hospitals for hypertension and diabetes, for early detection and treatment in adults

aged ≥ 30 years in order to stem the rising tide of CVD and diabetes in India. screening at the

SCs covering a population of 5,000 will be done by the health worker and involves assessment

of tobacco use and blood pressure measurement. Individuals at high risk will then be referred

to the CHCs (each covering a population of 1,00,000) and higher levels of care, for detailed

Current warnings notified for smoking in May, 2011


clinical evaluation and management. NPCDCS is expected to be integrated into the healthcare

system eventually and expanded to cover all the states and union territories in the 12th Five Year

Plan.1, 74

National Protocols and Guidelines for Management

● To provide equitable and cost-effective management for NCDs, the WHO and moHFW are currently reviewing the Indian Public Health standards (IPHs) and final recommendations for the NPCDCS have been submitted. IPHS includes recommendations on services, manpower, drugs, investigations and equipment to be provided at various levels of care.

● In 2005, the ICMR, with WHO’s support, prepared guidelines for management of type 2 diabetes.

● MoHFW, with assistance from the WHO, has developed guidelines for the management of ischemic heart disease, diabetes, stroke, dyslipidemia, and overweight / obesity for the NPCDCS.

● The WHO-India office has also facilitated the development of guidelines for the management of common cancers, COPD, asthma, and screening for cervical cancers.

All of these guidelines and diagnostic criteria need wider dissemination to increase uptake and

implementation. Evidence based guidelines for primary prevention of NCDs in India are also

under development.1

Initiatives for Surveillance

Cancer registries under the NCRP have provided data to understand the magnitude and

pattern of cancers in selected urban centres and for a few rural areas. These cancer registries

are providing information on incidence (which is not available for most diseases in India). This

enables systematic international comparison of age-adjusted incidence rate for cancers in

India, apart from tracking time trends within the country.

Integrated Disease Surveillance Project (IDSP)

This Government of India programme, launched in 2004, is an initiative primarily focused

on communicable disease surveillance. However, using the WHO STEPs methodology, IDSP

planned risk factor surveys in the country in three phases for NCD surveillance. Phase 1 has

been completed in a pilot mode in seven states. Phase 1 surveys mainly focused on CVD

risk factors in the population and there is a need to now collate information on associated

mortality, complications and health expenditure. There is potential for the development of a

comprehensive surveillance programme for NCDs and their risk factors.1

S E P T E M B E R 2011 31

Sentinel Surveillance of CVD risk factors in the Indian Industrial Population (SSIP)

The Initiative for Cardiovascular Health Research in Developing Countries (IC-HEALTH), New

Delhi, developed a Sentinel Surveillance System of Cardiovascular Disease Risk Factors in the

Indian Industrial Population (SSIP) which included ten diverse sites. SSIP was developed using

a public-private partnership model with participation of both public and private industrial

sectors. SSIP implemented a multi-component, multilevel, and multi-method intervention

which trained local healthcare personnel in the participating industries. The industry

setting was the target, agent, and resource, over four consecutive years. The intervention

included behavioral change strategies among the employees and their family members. The

intervention was implemented by a trained medical team comprising physicians, nutritionists

and social workers. A population-based approach of behaviour change was the key feature of

the intervention. This was augmented by high-risk individual counselling and policy change/

environment approaches. significant reductions in population risk factor levels including

weight, waist circumference, systolic and diastolic blood pressure, plasma glucose and total

cholesterol, were observed (Table 5). The risk for CVD was determined using the Framingham

10-year CVD risk score. The proportion of study participants with a 10-year CVD event risk score

of ≥ 10% significantly decreased from 34% at baseline to 27% at the final survey in the intervention

group, while the control group showed a significant elevation (25% to 35%).1

Table 5: Results of worksite programme for NCD risk reductionin seven industries across India

Intervention Sites (6) Control Site (1)Baseline Final Baseline Final

Weight, Kg 60.9 59.0 60.9 65.1SBP, mmHg 127.1 123.6 121.6 131.5Plasma Glucose, mg/dl 91.5 82.9 91.1 103.1Total Cholesterol, mg/dl 175.4 164.7 175.7 182.2HDL Cholesterol, mg/dl 44.4 49.0 39.0 40.6

Some other recent endeavours include the NCD risk factor surveillance conducted by the

ICMR, the prospective study on one million deaths in India currently undertaken by the

Registrar General of India’s (RGI) Sample Registration System (SRS) and the CARRS (Center

for cArdiometabolic Risk Reduction in South Asia) surveillance study initiated by the Public

Health Foundation of India.



IEC material to promote healthy eating and reducing risk of cardiovascular diseases

Tight Controlof

Blood Pressure

Regular RetinaExamination

Regular FeetExamination

Tight Controlof

Blood Sugar

Controlof

Blood Lipids

Annual UrineMicroalbuminExamination

S E P T E M B E R 2011 33

States explore tackling NCDs

In the recent past, some states such as Tamil Nadu (Box 2, 3) and Kerala have independently

implemented NCD prevention and control initiatives. The Tamil Nadu Health System Project

(TNHSP), is an example. TNHSP successfully piloted clinic based NCD control interventions that

are planned to be expanded to cover the whole state. In Kerala, the National Rural Health

Mission carried out a pilot intervention programme for diabetes and hypertension in two

districts providing screening and management services to the community with future plans to

cover the entire state.1

Box 2. NCD Intervention in Tamil Nadu

Government of Tamil Nadu, with the support of the World Bank, launched the Tamil Nadu

Health System Project (TNHSP) during 2005-2010. One of the four major components

of TNHSP was ‘Developing effective models to combat non-communicable diseases and

accidents’. The major elements of this initiative were health promotion and pilot testing of

clinic based interventions for NCD control.

Health promotion activities included Behaviour Change Communication (BCC) focused

on cardiovascular risk reduction within the community, workplace, and schools.

The community BCC was conducted by a local NGO. The school and worksite BCC

implementation was done in two pilot districts (in 25 intervention schools and 25 control

schools and 5 worksites each).

Clinic based interventions for NCD detection and management were developed and pilot

tested in two districts. These aimed to diagnose and treat hypertension as well as to

screen, treat, and refer women for cervical cancer.

The monitoring and evaluation for both the hypertension and the cervical cancer pilots

have been done by the National Institute of Epidemiology (NIE), Chennai. According to

an evaluation carried out by the World Bank, 1,231,259 people were screened (October

2007-March 2010) for hypertension and 98.61% (5,10,783 / 5,18,000) of target women were

screened for cervical cancer. The government is planning to expand this programme to

the entire state. The study demonstrated that a primary healthcare approach, involving

existing health services, can be very effective in the detection and control of high blood

pressure.

Source: Reference 1


Box 3. Rural Diabetes Intervention

The Madras Diabetes Research Foundation in Chennai initiated a rural diabetes prevention

programme in Chunampet, Tamil Nadu. The programme aims to prevent diabetes

in about 5,00,00 individuals residing in 42 villages, using village health workers and a

mobile telemedicine unit for screening. In addition, a diabetes centre to provide basic

care has been set up. Screening is free but about 60% patients pay for their treatment

at subsidised costs, with those who can’t afford being treated free of cost. To date

over 90% of the adult population in this area has been screened for diabetes. The mean

glycated haemoglobin levels among those diagnosed with diabetes has decreased from

9.3% to 8.5%. Additional use of telemedicine has facilitated screening for diabetes related

complications and referral when required for further evaluation and treatment.

Source: Reference 1, 2

S E P T E M B E R 2011 35

Starting Young

Programmes involving health promotion among young persons and health advocacy by youth

are of value in combating NCDs, both because of the need to enable greater awareness and

adoption of healthy living habits early in life and also in recognition of the powerful role of

youth as change agents in society.

Initiatives to promote healthy behaviours among school students have been implemented and

evaluated, in a series of cluster randomised trials since 1992, by Health Related Information

Dissemination Amongst Youth (HRIDAY), a youth centric NGO. Experimentation with

tobacco, regular use of tobacco and offer of tobacco by peers were all significantly reduced

in the schools which implemented the programme in comparison with control or delayed

intervention schools.76,77 The programme which also promotes healthy diets, physical activity

and environmental protection, has received a WHO award and is now being replicated by

other NGOs across India.

HRIDAY-SHAN youth health advocates endorsing their support for strong health promoting policies through a signature campaign


Recognizing the need for policy enabled social environments to support people in making and

maintaining healthy living choices, HRIDAY has also promoted informed advocacy by school

and college students through Student Health Action Network (SHAN). Students, who are

trained under this programme, debate policies, impart health education to neighbourhood

communities and engage policymakers and the media. HRIDAY-SHAN has also convened a

Global Youth Meet (GYM) in 2006 and 2009, and supports Youth For Health (Y4H), a global

youth network that campaigns for health promoting policies.

A HRIDAY-SHAN poster under the School Health Education Programme

S E P T E M B E R 2011 37

Public health strategies to prevent and control NCDs: the way forward

A comprehensive strategy for the prevention and control of NCDs must integrate

proven and effective public health interventions to minimize risk factor exposure at

the level of the population and reduce risk of disease related events in individuals

at high risk. Such a combination of the population approach and the high risk approach is

synergistically complementary, cost-effective, and sustainable; and provides the strategic

basis for early, medium and long term impact on NCDs in India.

Priority actions for NCD prevention and control in India

selected high priority cost-effective interventions are given in Table 6. A framework of

recommended options and actions for NCD prevention and control at different levels of

the healthcare system is given in Table 7, which can be suitably adapted depending on

the context.

Table 6. Some key suggested cost-effective interventions forNCD prevention and control

Risk Factor Interventions Cost Per Person/Year (INR)

Tobacco use effective implementation of COTPA 7.04

Dietary salt Consumer education using mass media, action by food industry 2.64

Overweight, physical inactivity, unhealthy diet

Mass media campaigns, taxes on unhealthy foods, subsidies for healthy foods, mandatory food labelling, marketing restrictions

15.40

Excess alcohol consumption Increased taxation, ban on advertisements and access restrictions 2.20

Cardiovascular risk reduction Using low cost drug combinations for high risk individuals 39.60

Total cost per person (INR) 66.88



Table 7. Framework of recommended options and actions for NCD prevention and control at various levels of the healthcare system

Services Stroke CHD and Diabetes

At PHC level

Screening and Diagnosis

● Identification of signs and symptoms of acute stroke, TIA

● Screening for HTN, DM, tobacco, OCP use

● Non-invasive screening (history, tobacco use, overweight / obesity)

● Screening for HTN, DM and their management with simple drugs

● ECG for diagnosis of acute presentations

Management Acute / Emergency

● ABC of resuscitation

● If not equipped to carry out acute management or in case of unstable /deteriorating condition, refer immediately to a tertiary care centre

● Evaluate the haemodynamic status (BP, heart rate, heart failure)

● Oral nitrates

● Aspirin

● Treatment of hypoglycaemia and diabetic coma

Chronic Care

● Prescription for secondary prevention

● Tobacco cessation for users

● Post-Stroke rehabilitation

● Secondary prevention of CHD


● Monitoring of BP and DM control

Follow-up life-style education, follow-up for compliance along with refill of medicines, referral of complicated cases and rehabilitation

At Sub-District level



● Screening for HTN, DM, tobacco, OCP use

● Investigations: ECG, Total cholesterol

● Non-invasive screening (history, tobacco use, overweight / obesity)

● Screening for HTN, DM and their management

● Investigations: ECG, Total cholesterol

● Diagnose and treat gestational DM / DM with pregnancy

● Treatment of DM with complications or comorbidities

● Diabetic emergency (hypoglycemia, ketosis, coma)


● ABC of resuscitation

● If not equipped to carry out acute management or in case of unstable/ deteriorating condition, refer immediately

● Temperature maintenance

● Evaluate the haemodynamic status (BP, heart rate, heart failure)

● Thrombolytic therapy

● Inpatient care for uncontrolled HTN

contd...

S E P T E M B E R 2011 39

Services Stroke CHD and Diabetes

Chronic Care

● Prescription of multiple drugs and anticoagulants



● Secondary prevention of CHD


● Treatment of HTN, DM with monitoring of control

Follow-upLife-style education, follow-up for compliance, investigations and change of prescriptions if needed, referral of complicated cases to a tertiary care centre, and rehabilitation

At District level



● Screening for HTN, DM, tobacco, cardiac diseases, OCP use

● Detailed investigations: CT scan in all cases, ECG, Pulse oximetry, 2D- ECHO, X-ray, Lipid profile

● Non-invasive screening (history, tobacco use, BMI, waist circumference)

● Screening for HTN and DM

● Investigations: eCG, X-ray, lipid profile, ECHO


● Inpatient care

● Management of BP with parenteral agents

● Supportive care

● Prophylaxis for DVT

● Acute rehabilitation

● Refer to a tertiary care centre in case of significant, pressure effects, or surgical candidates with haemorrhage

● Evaluate the haemodynamic status

(BP, heart rate, heart failure)

● Thrombolysis

● Inpatient care for uncontrolled HTN with end-organ complications

● In patient care for complications of DM (e.g., ketoacidosis, renal failure, serious infections)

Chronic Care

● Prescription of multiple drugs and anticoagulants



● Secondary prevention


● Treatment of HTN, DM with monitoring of control

Follow-up ● Life-style education, follow-up for compliance, investigations and change of

prescriptions if needed, referral of complicated cases to a tertiary care centre and rehabilitation

Abbreviations Used: HTN- Hypertension; bP- blood Pressure; Dm- Diabetes mellitus; OCP-Oral Contraceptive Pill; TIA-Transient Ischemic Attack; CHD- Coronary Heart Disease; DVT-Deep Vein Thrombosis

Source: Modified from reference 1


Building regular surveillance systems

The rising burden of NCDs calls for continued and concerted public health action based on

sound scientific evidence as well as on contextual factors. There is a paucity of nationally

representative and standardised data for most NCD risk factors and diseases in India. Given

the size and diversity of the population and the varied health transitions that are occurring,

large nationally representative studies and surveillance systems, to measure and monitor

trends of NCDs, their risks and associated mortality on a regular systematic basis are required.

Representative, contemporary and disaggregate data from these sources will enable adequate

and appropriate policies and timely public health action. In addition, this endeavor will also

help assess the quality of NCD related services delivered through the public and private health

sectors. Integration of data gathering systems at state and central levels as well expanding the

scope of surveillance, to sectors apart from the health sector, (to track consumption of foods

and substances influencing NCDs, such as fats, sugars, salt, oils, tobacco, and alcohol) will be

useful in devising a comprehensive response to NCDs.

Creating an evidence base

Research is critical for developing sound public health policies. A systematic review of scientific

literature originating from 90 countries has identified the deficiency of research related to

health systems, health policies, and quality of care in India.79 It is also essential to elucidate the

complex array of social, financial, behavioural, and organisational barriers that impede delivery

of high-quality NCD healthcare services. Some of the key research areas include: impact

and costs of innovative interventions to reduce NCD risk through health policy and health

services; methods for ensuring integration of NCD care within the existing health system and

programmes; appropriate health financing strategies for NCDs; and effective methods for

translating existing scientific knowledge to the development, implementation and evaluation

of NCD programmes.

Coordination of NCD initiatives

India has some NCD focused programmes, policies, and ongoing initiatives. However, it is

important to enable greater connectivity, sharing and cross-learning which may come from

close coordination and horizontal integration. Given that major NCDs have shared risks which

present multiple opportunities for prevention and control, an overarching policy, which

links actions in different sectors (health and non-health) and adopts a holistic approach to

prevention and reduction of common risk factors, is essential.

Strengthening the health system

To meet the increasing demands of delivering NCD related care, there is a critical need for

incorporating elements of prevention, surveillance, screening and management into all levels

of healthcare (primary, secondary, tertiary). Further, skills of diverse healthcare providers

S E P T E M B E R 2011 41

involved in NCD care and management require regular enhancement, strengthening and

updating (Box 4). Training of non-physician health workers, with special emphasis on NCDs,

should also be explored. The revived category of male Multi-Purpose Health Workers (MPHWs)

offers an opportunity to introduce NCD related functions into primary healthcare as does

the deployment of a second Auxiliary Nurse Midwife (ANM). Given the large population that

requires NCD services and the acute shortage of trained physicians, a nurse-practitioner system

should be introduced, where nurses can be trained to prescribe simple medications based on

evidence-based algorithms for uncomplicated cases of hypertension and diabetes, as well as

to undertake follow-up of such cases. Standardisation and accreditation of healthcare services

are also necessary to improve the quality of care, in both public and private sectors, given the

chronic nature of NCDs and long term care required. Improvement of the health system and

integration of NCD related prevention and treatment services will help provide more equitable

delivery of services and are likely to have a large impact on reducing the disease burden and

preventing much of the avertable mortality.

Establishing referral and follow-up systems

Given that NCDs require long term continued care, effective referral linkages and follow-up

processes, across different levels of the healthcare system (primary, secondary, tertiary), are

essential to increase operative efficiency and optimise costs. such systems are also needed to

ensure that patients receive timely treatment and follow-up interventions in a user friendly

manner when they navigate the healthcare system.

Box 4. Human Resource Development and use of Technology in NCD Prevention and Control

● Training a new cadre of community health workers (CHWs) or retraining existing CHWs who are no longer required in other national programmes (e.g., Leprosy, Guinea worm etc.) to cater to NCD related activities.

● Training of CHWs to assess NCD risk using simple techniques: - To measure blood pressure - To identify individuals at high risk of developing type 2 diabetes using non-laboratory

based risk scores - To provide lifestyle modification advice to persons with NCDs - To assist primary healthcare physicians in managing NCDs, by promoting adherence,

compliance and adequate follow-up

● Development of low cost, effective tools for incorporation in mobile phones for screening and management of NCDs through a decision support system.

● Establishment of a health management and intelligence system using information technology to integrate multiple data sources to track NCDs and their risks.

● Creation of learning tools including distance learning tools for physicians and CHWs in NCD management using low cost information technology.


Ensuring drug supply

Provision of uninterrupted, accessible, and affordable drug supply is another critical area.

The burden of many chronic NCDs can be substantially reduced with low cost generic drug

treatment. States can adopt the model of the Tamil Nadu Medical Supplies Corporation

where it purchases drugs at low prices and has developed a computer based drug inventory

management system.

Integration of NCDs into other relevant national programmes

This is vital given the shared risks and healthcare needs. A case in point is the well established

and functioning Revised National Tuberculosis Control Programme (RNTCP). Tobacco use,

a leading NCD risk factor is also now causally linked to tuberculosis (TB), with high levels of

smoking being reported among TB patients in India. Smoking also increases the risk of death in

patients with TB.Tobacco cessation interventions could easily be incorporated into the existing

programme for reducing tobacco use and improving TB related health outcomes, without

much additional financial or human resource costs. low birth weight and under nutrition

during early childhood increases the risk of CVD and diabetes subsequently in adulthood. Thus,

existing maternal and child health programmes can be leveraged to improve nutritional status

of mothers and children to prevent transgenerational transmission of NCD risk. At the same

time antenatal services and clinics could be utilised to provide education on healthy diets and

harm from tobacco including from exposure to second hand smoke.

Development and implementation of NCD clinical standards and guidelines

As the implementation of the NPCDCS is being scaled, the development of clinical standards

and guidelines will be critically important to facilitate wider use of low cost high impact

interventions. Ideally, they should be based on local evidence. In its absence, best care practices

from other countries can be suitably adapted to Indian needs, taking into consideration

contextual cost-effectiveness as well as capacity of the health system.

Providing patient education and enabling self-care and management

Health system constraints, due to shortage of resources and providers, can be addressed to a

great extent by empowering patients and communities with necessary information on NCDs,

that they can utilise to engage in self-monitoring and self-care. This can facilitate achievement

of improved health outcomes, reduce unnecessary hospital visits, admissions / hospitalisations

and periodicity of follow-up visits, considerably contributing to cost savings for the health

system.

S E P T E M B E R 2011 43

Promoting non-health sector involvement in developing policies for NCDs and initiating multi-sectoral action

Considering the role of multiple upstream determinants of NCDs which lie out of the health

sector, such as poverty, education, social and cultural influences as well as economic and

environmental factors determining diet and activity patterns, formulation of NCD control

policies need to be comprehensive. They should involve a “Whole of Government” or “Health in

all Government policies” approach with participation of multiple government ministries such as

health, finance, excise and taxes, home, education, agriculture, civil supplies, food processing,

urban and rural development, transport, women and child development, commerce,

environment, local self-government and panchayat raj, information and communication.

In addition, participation of civil society organisations, private health sector, media, donor

organisations and corporates is equally important to devise policies and programmes which

will find wide acceptability, an essential criterion for successful implementation.

The private sector can play a significant role in promoting healthy diets and physical activity,

limiting levels of saturated fats, trans-fatty acids, free sugars and salt, increasing availability

of healthy and nutritious food choices and reviewing current market practices. Enabling

policies could result in effective Public Private Partnerships (PPP) which would benefit people

from all socio-economic strata.

In order to effectively coordinate these multiple stakeholders, the health ministry, both at the

central and state levels, would require a cadre of public health professionals (epidemiologists,

health economists, health management specialists, nutritionists) who can assist with

developing evidence based NCD policies, cost-effective NCD programmes, and facilitate

monitoring and evaluation of such policies and programmes. Health impact assessment, of

proposed policies and programmes in other sectors which may influence the determinants of

NCDs, should be prospectively undertaken.

Implementing healthy public policies

Tobacco and alcohol control

legislative efforts to control tobacco use have led to India being a signatory to the Framework

Convention on Tobacco Control (FCTC) and the implementation of the COTPA, 2003. This Act

mandates smoke bans in public and work places, ban on advertisements, prohibition of sales to

and by minors, regulation of the contents of tobacco products and graphical health warnings

on tobacco product packages. Though tobacco control policies are quite well developed, their

implementation and enforcement under the aegis of the National Tobacco Control Programme

need to be more effective and still require substantial improvement to drive reductions in

tobacco use and related NCDs.


In contrast to tobacco, alcohol policies are limited in mandate to advertisement bans in print

media and sale restriction to minors. more effective policies are clearly required to reduce

consumption but the political will for action is impeded by the huge revenues that alcohol sales

accrue to state governments.

Injury control

Current data and projections suggest a huge and growing burden of injuries, particularly road

traffic injuries. Policies could initially focus on behavior change directed at use of seat belts /

helmets, reduction of drunk driving and inculcating safe pedestrian habits. In addition, pre-

hospital trauma care needs to be strengthened to avoid premature death and disability.

Other policies

Other supporting legislative efforts can include bans on misleading advertisement of junk foods

and targeting of children, regulating food safety, mandating food labelling, ban on trans-fats

and policies for salt reduction.

Given the enormous but not insurmountable challenge posed by the escalating burden of

NCDs, strong public health action and commitment to implementing proven and effective

interventions is required. In the milieu of a resource constrained health system, a combined

strategy, incorporating interventions targeted at the whole population as well as those

focused on individuals at high risk of developing disease and those with established disease,

will help reverse the rising tide of NCDs in India.

S E P T E M B E R 2011 45

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