Phfi NCD Report Sep 2011

Chronic Non-Communicable Diseases in 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. Its 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
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
he 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
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 countrys 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, Indias 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 Indias 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 centurys greatest health threat.
K. Srinath Reddy
President Public Health Foundation of India
CONTENTS
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
1 3 11 21 25 37
LIST OF ABBREVIATIONS
ABC ANM ATS BCC BMI BP CARRS CHC CHD CHW COPD COTPA CVD DALYs DM DVT ECG ECHO FCTC GATS GYM GYTS HDL HRIDAY HTN IC-HEALTH ICMR IDSP IEC IGT IHD IPHS LDL Airway Breathing Circulation Auxiliary Nurse Midwife Adult Tobacco Survey Behaviour Change Communication Body Mass Index Blood Pressure Center for cArdiometabolic Risk Reduction in South Asia Community Health Centre Coronary Heart Disease Community Health Worker Chronic Obstructive Pulmonary Disease Cigarettes and Other Tobacco Products Act Cardio Vascular Disease Disability Adjusted Life Years Diabetes Mellitus Deep Vein Thrombosis Electrocardiogram Echocardiogram Framework Convention on Tobacco Control Global Adult Tobacco Survey Global Youth Meet Global Youth Tobacco Survey High Density Lipoprotein Health Related Information Dissemination Amongst Youth Hypertension Initiative for Cardiovascular Health Research in Developing Countries Indian Council of Medical Research Integrated Disease Surveillance Project Information Education Communication Impaired Glucose Tolerance Ischemic Heart Disease Indian Public Health Standards Low Density Lipoprotein
MoHFW MPHW NCCP NCD NCMH NCRP NFHS NGO NIE NMHP NPCB NPDCS NPCDCS NTCP OCP PHC PHFI PPLL PPP RCC RDA RGI RNTCP SBP SC SRS SSIP TB TIA TNHSP TORCH WC WHO WHS Y4H
Ministry of Health and Family Welfare Multi Purpose Health Worker National Cancer Control Programme Non-Communicable Disease National Commission on Macro Economics and Health National Cancer Registry Programme National Family Health Survey Non-Governmental Organisation National Institute of Epidemiology National Mental Health Programme National Programme for Control of Blindness National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke National Programme on Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke National Tobacco Control Programme Oral Contraceptive Pill Primary Health Centre Public Health Foundation of India Potential Productive Life Lost (years) Public Private Partnership Regional Cancer Centre Recommended Daily Allowance Registrar General of India Revised National Tuberculosis Control Programme Systolic Blood Pressure Sub-Centre Sample Registration System Sentinel Surveillance System for Cardiovascular Disease Risk Factors in the Indian Industrial Population Tuberculosis Transient Ischaemic Attack Tamil Nadu Health System Project Toxoplasmosis Other Rubella Cytomegalovirus Herpes simplex virus infections Waist Circumference World Health Organisation World Health Survey Youth For Health
OVERVIEW
s 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.
S E P T E M B E R 2011
CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE
Rise in NCDs and their risk factors
t 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
Source: Adapted from reference 1
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.
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
Smoking Causes Nearly 1 Million Deaths

The poor are disproportionately affected Over 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
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
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 sixthgrade 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.
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 highdensity 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

Calorie intake (kcal/person/day) Protein intake (grams/person/day) Fat intake (grams/person/day) Oil intake (grams/person/day) Percent share of total dietary intake Carbohydrate Protein Fat Oil consumption (in million tonnes) 1990-1992 2320 56 41 18 1995-1997 2380 58 46 21 2003-2005 2360 56 52 27
75 10 16 1993 5.8
73 10 17 2003 10.5
71 10 20 2007 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
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 Nutritions 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 onethird 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.
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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
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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)
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
12
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. Ageadjusted 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 evidencebased, 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
13
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
Source: Reference 45, 46, 47
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
14
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-Hodgkins lymphoma in women and for the cancers of esophagus, prostrate, mouth and non-Hodgkins 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
15
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
16
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
Source: Reference 58
Figure 6: Road traffic accident deaths by type of vehicle (%)
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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.
18
Table 2. Developmental disabilities in children: some risk factors and causal associations
Diseases such as TORCH infections in mother Exposure to radiation, harmful drugs Developmental Poor nutrition and defects in brain due to disturbed metabolism gene abnormality as in maternal diabetes Severe forms of blood groups or Rh incompatibility Disturbed circulation of the foetus due to maternal hypertension, toxaemia of pregnancy Hypoxia (birth asphyxia) from premature separation of placenta Metabolic disturbances and infections in the new born Poisoning or accidental ingestion of toxins After Birth Rarer causes such as brain tumours Before Birth
Prolonged labour and compression of brain Cardio respiratory problems in baby causing relative lack of oxygen to babys brain Diseases such as meningitis, encephalitis, measles Anoxia from drowning, severe respiratory problems
Head injuries related to obstetric causes Pre-maturity and susceptibility of brain to haemorrhage (bleed) Head injuries in early infancy and childhood Vascular accidents and intracranial bleeds associated with metabolic disturbances
At Birth
19
20
Role of socioeconomic transition in the rise of NCDs
ndia 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).
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Figure 7: NCD burden and intervention coverage among different social groups in India
(A-Burden of disease, B-Intervention coverage, Q1-Poorest quartile, Q4-Richest quartile)
Prevalence in population (%)
Angina
Depression
Diabetes
Road Injury
Coverage in population (%)
Angina
Depression
Diabetes
Road Injury
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).
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Table 3. Cardiovascular risk factors by educational status in an Indian industrial population (%)
Risk Factor Tobacco use Men Women Hypertension Men Women Overweight Men Women Diabetes Men Women 19.8 1.2 27.2 15.3 37.0 39.3 8.4 4.2 26.5 1.6 29.9 18.4 33.1 37.4 10.4 4.8 40.2 2.7 28.6 23.8 30.4 41.5 13.3 9.8 77.3 42.1 32.6 34.7 9.1 22.9 7.6 11.2 < 0.001 < 0.001 0.05 < 0.001 < 0.001 < 0.001 0.08 0.01 ES I ES II ES III ES IV P-value for Trend
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.
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Current initiatives for NCD prevention and control
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 Welfares (MoHFW) outlay for the 11th Five Year Plan of 2007-2012 (Table 4).1
he 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
Table 4. Proposed allocation for NCD programmes in the 11th Five Year Plan
Programme National Programme on Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS) National Trauma Care Programme National Cancer Control Programme All NCD Control Programmes * Communicable Disease Control Programmes Total Proposed Outlay (Million INR) 12,500 10,303 20,000 66,586 1,72,641 2,40,222 Percent of Total Outlay 5% 4% 8% 28% 72% 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.
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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 programmes 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
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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
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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
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Current warnings notified for smoking in May, 2011
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 programmes 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 subcentres (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
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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 WHOs 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
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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 reduction in seven industries across India
Intervention Sites (6) Baseline Final 60.9 59.0 127.1 123.6 91.5 82.9 175.4 164.7 44.4 49.0 Control Site (1) Baseline Final 60.9 65.1 121.6 131.5 91.1 103.1 175.7 182.2 39.0 40.6
Weight, Kg SBP, mmHg Plasma Glucose, mg/dl Total Cholesterol, mg/dl HDL Cholesterol, mg/dl
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 Indias (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.
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Tight Control of Blood Sugar Control of Blood Lipids Tight Control of Blood Pressure
Regular Retina Examination
Annual Urine Microalbumin Examination
Regular Feet Examination
IEC material to promote healthy eating and reducing risk of cardiovascular diseases
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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
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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 cant 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
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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
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A HRIDAY-SHAN poster under the School Health Education Programme
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.
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Public health strategies to prevent and control NCDs: the way forward
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 for NCD prevention and control
Risk Factor Tobacco use Interventions Cost Per Person/ Year (INR) 7.04 2.64
effective implementation of COTPA Consumer education using mass media, Dietary salt action by food industry Mass media campaigns, taxes on Overweight, physical unhealthy foods, subsidies for healthy inactivity, unhealthy diet foods, mandatory food labelling, marketing restrictions Increased taxation, ban on Excess alcohol consumption advertisements and access restrictions Using low cost drug combinations for Cardiovascular risk reduction high risk individuals Total cost per person (INR)
15.40
2.20 39.60 66.88
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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 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 Prescription for secondary prevention Post-Stroke rehabilitation
Non-invasive screening (history, tobacco use, overweight / obesity) Screening for HTN, DM and their management with simple drugs ECG for diagnosis of acute presentations Evaluate the haemodynamic status (BP, heart rate, heart failure) Oral nitrates Aspirin Treatment of hypoglycaemia and diabetic coma Secondary prevention of CHD Tobacco cessation for users Monitoring of BP and DM control
Management Acute / Emergency
Chronic Care
Tobacco cessation for users
Follow-up
life-style education, follow-up for compliance along with refill of medicines, referral of complicated cases and rehabilitation At Sub-District level
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) Evaluate the haemodynamic status (BP, heart rate, heart failure) Thrombolytic therapy Inpatient care for uncontrolled HTN
contd...
Identification of signs and symptoms of acute stroke, TIA Screening for HTN, DM, tobacco, OCP use Investigations: ECG, Total cholesterol
ABC of resuscitation If not equipped to carry out acute management or in case of unstable/ deteriorating condition, refer immediately Temperature maintenance
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Services
Stroke
CHD and Diabetes

Chronic Care
Prescription of multiple drugs and anticoagulants Post-Stroke rehabilitation
Secondary prevention of CHD Tobacco cessation for users 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 At District level
Identification of signs and symptoms of acute stroke, TIA 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 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 Prescription of multiple drugs and anticoagulants Post-Stroke rehabilitation
Non-invasive screening (history, tobacco use, BMI, waist circumference) Screening for HTN and DM Investigations: eCG, X-ray, lipid profile, ECHO
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)
Secondary prevention Tobacco cessation for users Treatment of HTN, DM with monitoring of control
Chronic Care
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
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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
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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.
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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.
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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.
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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, prehospital 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.
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References
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Chronic Non-Communicable Diseases in India

Reversing the tide

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Rise in NCDs and their risk factors

Figure 1: Cause specific mortality in India

Source: Adapted from reference 1

Source: Adapted from reference 2

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Smoking Causes Nearly 1 Million Deaths

Figure 3: High tobacco consumption in India

Source: Adapted from reference 5

Overweight and obesity

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Dietary change in India

Table 1. Dietary changes in India

Changing Food Habits

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Surging NCD burden

Source: Adapted from reference 34

High blood pressure

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Source: Adapted from reference 36

Diabetes: Dire Warnings

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Combating Cancer: The Case for Action

Chronic obstructive pulmonary disease

Mental health disorders

Road traffic accidents and injuries

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Bringing Road Traffic Accidents and Injuries to a Halt

Figure 6: Road traffic accident deaths by type of vehicle (%)

Source: Adapted from reference 60

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Source: Adapted from reference 64

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Role of socioeconomic transition in the rise of NCDs

Prevalence in population (%)

Coverage in population (%)

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Current initiatives for NCD prevention and control

Existing programmes for NCDs

National Cancer Control Programme

National Trauma Control Programme

National Programme for Control of Blindness

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

National Mental Health Programme

Box 1. Potential Cost Effective Interventions for Mental Health Disorders

National Tobacco Control Programme

Existing health warnings for smoked and smokeless tobacco products

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Current warnings notified for smoking in May, 2011

National Protocols and Guidelines for Management

Initiatives for Surveillance

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

Regular Retina Examination

Annual Urine Microalbumin Examination

Regular Feet Examination

CHRONIC NON-COmmuNICAble DIseAses IN INDIA REVERSING THE TIDE

States explore tackling NCDs

Box 2. NCD Intervention in Tamil Nadu