Health of India’s states: What the latest health report means
The phase of epidemiological transition is finally over. India: Health of the Nation’s States released on November 14, 2017 shows data to prove that non-communicable diseases now contribute more to India’s disease burden than communicable diseases. However, we still face a double burden of disease and non-communicable diseases are just the bigger burden.
In the last 26 years, diabetes increased by 174 per cent and Ischaemic Heart Disease (IHD) went up by 104 per cent. IHD and Chronic Obstructive Pulmonary Disease (COPD) were the leading causes of premature death and ill-health in 2016, overtaking lower respiratory infections and diarrhoeal diseases. However, the transition does not mean that communicable diseases are taken care of.
The report provides a comparison between the disease burden, measured as Disability-adjusted life years (DALYs), in 1990 and 2016. The comparison shows that the disease burden due to communicable, maternal, neonatal and nutritional diseases (CMNNDs) is down from 61 per cent to 33 per cent during this period; while non-communicable diseases have gone up from 30 per cent to 55 per cent. During this same period, disease burden due to injuries went up from 9 per cent to 12 per cent.
In 2016, the levels of non-communicable diseases vary from 48 per cent to 75 per cent. For infectious and associated diseases, the variation is from 14 per cent to 43 per cent, and for injuries, it is between 9 per cent and 14 per cent.
Kerala, Goa and Tamil Nadu have clearly transitioned while Bihar, Jharkhand, Uttar Pradesh and Rajasthan are still in the process. The report also provides a comparison of the epidemiological transition ratio, defined as the ratio of Disability Adjusted Life Years (DALYs) caused by CMNNDs to those caused by NCDs and injuries shows a wide disparity amongst the states. In Kerala, this ratio is 0.16 compared to Bihar, where the ratio is 0.74. States with higher the ratio face more challenge from the double burden of diseases.
The data also shows that each state is unique. The health inequality between the states is stark. Madhya Pradesh and Uttar Pradesh both have a relatively lower level of development indicators and are at a similar less advanced epidemiological transition stage. However, Uttar Pradesh had 50 per cent higher disease burden per person from chronic obstructive pulmonary disease, 54 per cent higher burden from tuberculosis, and 30 per cent higher burden from diarrhoeal diseases. Madhya Pradesh had 76 per cent higher disease burden per person from stroke. The two adjoining north Indian states of Himachal Pradesh and Punjab both have a relatively higher level of development indicators and are also at a similar more advanced epidemiological transition stage. However, Punjab had 157 per cent higher per person burden from diabetes, 134 per cent higher burden from IHD, 49 per cent higher burden from stroke, and 56 per cent higher burden from road injuries. On the other hand, Himachal Pradesh had 63 per cent higher per person burden from COPD.
The report also looks at 17 risk factors that are contributing to the disease burden in India. However, in our latest annual publication Body Burden: Lifestyle Diseases, we find that risk factors such as environmental toxins, stress and climate change need to be considered as well to devise strategies. The Indian Council of Medical research’s report includes “other environmental risks” but doesn’t discuss in enough detail to understand whether chemicals such as, polychlorinated biphenyls, phthalates and pesticides have been considered or not. Body Burden has found these to be important triggers of diseases such as diabetes, cancers and heart diseases. Tackling these risk factors is difficult.
The World Health Organization (WHO) says by investing just US $1-3 per person per year, countries can dramatically reduce illness and deaths from this group of diseases. However, the cost will be much higher as WHO identifies only four (alcohol, tobacco, poor diet and lack of physical activity) risk factors.
The report would be used for data-driven and decentralised health planning and monitoring recommended by the National Health Policy 2017 and the NITI Aayog Action Agenda 2017–2020. But the report flags the issue of lack of primary data, which could be a problem for policy makers. For example, the latest comprehensive data on the economic burden of non-communicable diseases was calculated more than a decade ago by the National Commission on Macroeconomics and Health, in 2005. Estimates of expenditure to prevent and treat these chronic diseases—which require life-long treatment—are necessary to devise a health financing plan. This is the lacuna that needs to be filled in the future. Soumya Swaminathan, who headed ICMR till a few days back and is the newly-appointed deputy director general of World Health Organisation in Geneva suggested that this report is published every three years.
The data would help but might not be the solution. At the release of the report, expert after expert talked about the need for multisectoral efforts to take care of the risk factors. Experience suggests that this would take more effort than just putting the data together.