Changing lifestyles have led to an alarming growth of NCDs in India. Realising the need to tackle this menace and the burden it poses on the economy, the government has prepared a draft policy for NCDs with several amendments to the earlier NPCDCS and intends to legislate it soon. By Usha Sharma
Premature deaths caused by non-communicable diseases (NCDs) such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes have risen drastically and each year nearly 5.8 million Indians die from these ailments. In other words, one in four Indians risks dying from NCDs before the age of 70. According to the World Health Organisation (WHO), more than 80 per cent of all NCD deaths are attributed to four diseases namely, cardiovascular, cancers, chronic respiratory and diabetes. These diseases occur due to multiple factors like demographic change in population, nutritional change with high calorie food consumption, low physical activity levels, etc. An AIOCD/AWACS report for MAT June 2015 states that cardiac segment at Rs 11,204 crores is growing at 14.2 per cent while anti-diabetics at Rs 7,092 crores is growing at 26.3 per cent.
Dr Ajit Dangi, President and Chief Executive Officer, Danssen Consulting says, “Although the situation looks grim, this burden can be significantly reduced by concerted actions as several effective options exist.”
Nilaya Varma, Partner and Head, Government & Healthcare, KPMG in India, while quoting a report from the International Diabetes Federation, states that India is expected to see an increase in diabetic population to 101.1 million contributed by 8.4 per cent of India’s adult population by 2030.
Referring to the report, Chronic diseases in India: Burden and implications,” on the Swiss Re Centre for Global Dialogue website, he mentions that along with diabetes, cases of hypertension are also expected to increase up to 213 million by 2025. Both diabetes and hypertension are attributable to higher risk factor burden for increased cardiovascular disease cases. Going forward, NCDs are expected to increase death burden by up to 68 per cent by 2030 wherein cardiovascular diseases are projected to be the major contributors, attributing to 54 per cent of NCD associated deaths. These projections look scary and indicate that NCDs are going to be responsible for more deaths in India than injuries, maternal, communicable and nutritional conditions.
This is in addition to many health related issues which impact quality of life. So the question arises, is the government of India geared up to handle the situation?
A key role
Well, atleast attempts to bring the situation under control are underway. The Ministry of Health and Family Welfare (MoHFW), Government of India, has formulated a draft policy on NCDs. It was scheduled to be introduced in February 2015, but got delayed due to several reasons. Revealing that the policy will be launched soon, Dr Damodar Bachani, Deputy Commissioner (NCD), Ministry of Health & Family Welfare Government of India says, “The Ministry of Health and Family Welfare has received numerous suggestions and comments on the draft policy. An expert group is examining them for its inclusion and hence is taking more time to get finalised.”
From the industry side, Varma, says, “Policies and guidelines developed in the draft National Health Policy 2015 regarding financial allocations, framework for various programme implementation, etc. are now clearly defined. Moreover, the government has received suggestions from various stakeholders to be included in the draft policy.”
The government’s action plan and framework for prevention and control of NCDs in India has also gone through some changes. As per the National Action Plan and Monitoring Framework for Prevention and Control of NCDs in India, NCDs have surpassed communicable disease as the most common causes of morbidity and premature mortality in the country. Hence, the Ministry has launched the National Programme for Preventive and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) in 2010 by merging the National Cancer Control Programme and the National Programme for Prevention and Control of Diabetes and Stroke. The programme is being implemented in 100 districts and is due to be expanded to cover all districts of the country in a phased manner during the 12th Five Year Plan.
The government later felt the urge to reduce the risk associated with NCDs and drafted guidelines around this intent. Varma shares the insight of the draft and presents, “The draft National Health Policy 2015 supports the development of an integrated approach to screen NCDs at an early stage in primary care centres to reduce the morbidity and mortality rates. It is also expected that specialist consultations would be provided to patients at primary level itself, together with regular follow ups. Suitable access to medication for chronic illness on a long-term basis is also on the primacy list for the government. A national programme on NCDs has also been visualised that can provide necessary resources and capacity building support to be functional at the district level. Since NCDs require lifelong management, the draft National Health Policy suggests that mainstreaming AYUSH could effectively prevent and provide cost effective treatment options to patients.”
Dr Dangi says, “The draft plan includes interventions like wellness awareness campaigns for lifestyle modifications, early and better diagnostic and screening facilities, emergency medical services, rehabilitation and palliative care, human resource and capacity building etc. As in any action plan of such magnitude, financial funding will remain a crucial factor.”
The suggestions from industry on the draft National Health Policy 2015 are well defined but the questions remains on how to execute it?
Dangi adds, “With the government healthcare budget of just over one per cent of gross domestic product (GDP), its implementation will remain a challenge. Several other avenues such as public private partnership (PPP) model, assistance from NGOs, national and international, funding from international bodies such as WHO, World Bank, UN etc. should also be explored. While burden of NCDs in a developing country like India cannot be eliminated, it can be reduced significantly by appropriate interventions.”
Planning policy is made more difficult when the data itself is questionable. As Dangi opines, “The first step is to collect reasonably accurate data on the incidence and prevalence of each of the NCD and then devise focused and dedicated strategies to manage and control these diseases. While the one-size-fits-all approach is unlikely to be effective, integrated and co-ordinated efforts are necessary as there is a common link between many NCDs. Identifying the key risk factors is the next step. The risk factors include alcohol and tobacco abuse, environmental pollution, sedentary lifestyle, nutritional deficiency, increasing life expectancy, urbanisation, burgeoning population and often genetics. Each of these risk factors need appropriate intervention. In a country like India, socio-economic inequalities add to the complexity.”
Several suggestions have been made to the draft policy. For example, Ranjana Smetacek, Director General, Organisation of Pharmaceutical Producers of India (OPPI) informs, “In our suggestions on non-communicable diseases in the draft National Health Policy 2015, the OPPI has suggested that it is important to develop and implement an integrated approach to urban health through behavioural change, supplemented by modern technological and social approaches to public services.”
Also on OPPI’s list is the establishment of a ‘complimentary research network’ of private healthcare companies to focus on disease awareness of NCDs and vaccines for preventable diseases as well as collaboration with industry partners to create disease awareness, early diagnosis and best in class treatment. As an example, she mentions AstraZeneca’s Youth Health Programme in Brazil, China, India and Zambia in collaboration with government authorities to focus on awareness and prevention of NCDs amongst adolescents in marginalised communities.
She further says, “Utilisation of CSR budget of pharma companies on healthcare related initiatives is the need besides capacity building, particularly of existing government facilities, to create trust among the masses, which could be achieved through awareness campaigns.”
Measuring the disease burden
Speaking at a recent the industry event in Mumbai CM Reddy, Chief Scientific Officer, Innovertus Nutrition Technologies delivered a speech on the role of nutraceuticals and highlighted the fact that in the last four decades, lifestyles in India have changed drastically. Recalling the first census programme, which was started one year after the independence in 1948 and completed in 1952, it was recorded that only six per cent of the total population were on medication whereas, last census report reflects that 69 per cent of today’s population relies on some form of medication. This shows that over a period of time as lifestyles change, associated chronic diseases have increased.
The approaching disease burden, looks challenging, particularly for a country like India, where most of the health spend is out of pocket. In such a scenario, should the government consider handling each disease portfolio individually and prepare separate policies or club them into one policy?
The latter approach seems to be favoured by one section. As Varma opines, “The treatment journey needs a separate policy for individual diseases as the treatments are long term, expensive and require a different plan of care for each disease. A comprehensive policy framework would be required for capacity building and establishing an effective healthcare network for rehabilitative and palliative care. Altogether, the economic disparity amongst the population, cultural diversity and different treatment journey makes it imperative to invest in separate programmes for management of NCDs.”
He emphasises, “Though cardiovascular disease is the major segment contributing to increased NCD burden, the risk factors which act as precursor for all leading NCDs are typically common. Most of the premature deaths from NCDs are related to high tobacco and alcohol usage, unhealthy diet and physical inactivity due to changing life styles. Policy makers now need to streamline their efforts to create public policies for healthy living while strengthening focus on prevention, screening and monitoring of diseases. Specific emphasis should be on awareness and health promotion while accentuating on improving dietary and lifestyle habits. NCDs like cancer, diabetes, cardiovascular diseases and chronic respiratory diseases are chronic in nature where effective lifestyle changes can just boost the health status of individuals.”
The PPP model has had mixed success in India so could PPPs be an option to handle NCDs? Bachani says, “Every stakeholder has a role to play. While healthy public policies and population-based public health interventions are within the domain of the government (Central/ State), provision of affordable, accessible and quality healthcare is the responsibility of healthcare providers, be it government, NGOs or the private healthcare sector.”
Impact on economy
The projected disease burden of NCDs are huge. If we do not control the growing incidence of NCDs it will have significant adverse impact on the Indian economy as well. Mindful of this reality, the government has included the NCDs in the National Health Policy 2015.
Commenting on the ways to reduce NCDs in the long term, Bachani highlights, “Preventing and managing chronic NCDs have a significant bearing on the economy. Firstly, by reducing incidence of (new) cases through risk reduction, you are improving life expectancy and better quality of life (thus improved productivity) and thus better economic development. Secondly, by identifying NCDs at early stages (through screening, periodic check-up), you are reducing costs of treatment. Treatment at early stage is cheaper (e.g. many cancers in stage I and II can be treated and even cured by surgery but advanced stages require very costly treatment (radiotherapy or chemotherapy) and even then survival is short. Diabetes without complications can be managed at low expenses but diabetes with kidney failure may require frequent dialysis, which is costly. Investment in prevention and control of NCDs has therefore been cost-effective in long run. As of now NCDs are creeping even in poor and rural populations, economic implications could be disastrous.”
Highlighting projections from the World Economic Forum and the Harvard School of Public Health, Varma refers to the report on ‘Economics of Non-Communicable Diseases in India, World Economic Forum, November 2014, p23) (based on 2010 dollars’ mentions, “NCDs are expected to lead to as much as $4.58 trillion loss of output between 2012-30. CVDs are major contributors to the economic burden in NCDs.”
Varma also refers to the November 2014 World Economic Forum Report titled ‘Economics of Non-Communicable Diseases in India’ which states that NCDs were responsible for more disability-adjusted life years (DALYs) in 2010 (~235 million) than communicable diseases (~222 million) in India. Diabetes is one of the major concerns in India, as number of DALYs due to the disease nearly doubled from approximately 4.1 to 8 million, from 1990 to 2010. Hence, NCDs are going to impact India on various aspects such as productivity, wellness, economic loss and burden on healthcare infrastructure.
Bachani has rightly mentioned that early stage diagnosis and treatment will ease the cost of treatment and will not affect the economy as badly as targeted.
The paradigm shift from communicable diseases to NCDs needs to be addressed with a focused approach from all stakeholders involved, feels Varma. He says, “India’s healthcare sector needs pressing attention from the government to address the gap present in the current system. Policies and guidelines developed in the draft National Health Policy 2015 regarding financial allocations, framework for various programme implementation, etc. are now clearly defined. NCDs have been included in the draft National Health Policy 2015 for the first time and it is a welcome step towards the vision for healthy India.”
He also feels , “It is crucial for the government and private sector to work in close coordination to identify effective solutions to reduce NCDs burden. A cohesive action plan that incorporates effective public as well as private healthcare interventions to minimise risk factor exposure is necessary. The combined efforts of government and the private sector should focus on capacity building of super-speciality hospitals, strengthening primary care, creating awareness on healthy lifestyle and coordinated movement of all public and private healthcare centres.”
While referring to WHO Action Plan 2013-2020, Dangi says, “The WHO Global Action Plan 2013-2020 for the prevention and control of NCDs outlines nine global targets. India must commit to achieving these targets in a time bound manner to ensure that public health and its impact on our economy is not compromised.”
Varma says, “India also needs to develop a national database on NCDs which can help in making informed decisions regarding allocation of resources and can also help in sharing best practices among medical professionals. Different states have also started taking initiatives to cater to NCD challenges, however, there is a need to follow a more collaborative approach to address growing concerns. It is high time now that the government finalises and releases the policies and programmes mentioned in the draft National Health Policy 2015 with appropriate budget allocations.”
NCDs have already taken firm root in India and shows no sign of decreasing. It is a no brainer that the impact of NCDs on our lives, not to mention the Indian economy will be drastic. Thus, it is the right time for both the public and private players to come together and form sound policies and strategies to control the growth of NCDs for a better tomorrow!