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India in Transition

Non-Communicable Diseases in India: Dispensing with the Global and Zeroing In on the Domestic

Karthik Nachiappan
February 23, 2015

Near the end of President Obama’s recent visit to India, he recorded a radio broadcast with Prime Minister Modi. On the air, Obama indicated a desire to work on public health issues in India once his term ends. One of the issues he referred to, in particular, was obesity, a growing health challenge worldwide. Obesity contributes to several non-communicable diseases (NCDs) that have been garnering more international attention. NCDs refer to health challenges that are largely chronic, evolve gradually, and get progressively worse until tackled. Across the world, health profiles are shifting due to increasing global linkages, rapid urbanization and sedentary lifestyles. These trends are making NCDs a leading cause of mortality, imposing stiff burdens on individuals, families, health systems, and governments.

In India, the NCD problem is quite serious. According to the Global Status Report on NCDs 2014, these diseases contributed to 5.8 million deaths, accounting for 60 percent of all deaths in India. Four major NCDs are responsible for these figures: cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes. These four diseases, in turn, are largely caused by four behavioral risk factors: tobacco use, unhealthy diet, physical inactivity, and alcohol use. Tied to these lifestyle choices are additional risk factors including obesity, high blood pressure, and high levels of cholesterol and blood glucose. The long-term implications of these trends are troubling for a young country like India; WHO estimates indicate that the probability of dying between thirty and seventy years of age from any of the four major NCDs in India is roughly 26 percent, which means that a thirty-year-old has a one-quarter chance of dying from any of these diseases before he or she turns seventy.

NCDs are being taken more seriously at the global health level. A decade ago, the WHO led the institution of a Framework Convention on Tobacco Control (FCTC) that has now been signed by almost 165 countries. Recently, the United Nations General Assembly convened a High-Level Meeting on the Prevention and Control of Non-Communicable Diseases in September 2011. Out of this meeting came a monitoring framework for the prevention and control of NCDs inclusive of a series of voluntary targets and indicators for countries to tailor and implement. But the international push has been rather piecemeal and ineffectual in nature. The existing global health architecture has not pivoted robustly to make a dent on chronic diseases for two reasons.

First,  these challenges are caused by broader economic and social conditions like inequality, inadequate food, water, shelter, and sanitation that are governed by various institutional entities within countries. Health concerns are not generally considered here. Second, these challenges are inherently difficult to address through international campaigns; interventions are relatively easier to mount, for instance, infectious diseases, where you can measure their impact and efficacy in due course. The NCD cause is a generational one that makes it difficult for global health actors to erect targeted and quantifiable interventions. Politically, the WHO has failed to muster enough support from key member states to focus on NCDs since it requires greater engagement with other ministries like finance, commerce, housing and transportation that do not directly deal with the WHO, dimming the organization’s influence and traction.

Until the 2011 UN meeting on NCDs, India did not have a core policy on NCD prevention and care, choosing instead to manage these diseases individually. India also did not spend much time advocating for NCDs, given its reliance on the WHO and international donors like the Global Fund and Global Alliance for Vaccines and Immunisation to tackle infectious diseases within the country. New Delhi did, however, respond positively when the WHO shifted gears on NCDs; India is the first country to begin adapting the global NCD monitoring framework to its national context. Plans are afoot to implement targeted interventions aimed at achieving nearly two dozen NCD indicators, including marked reductions in alcohol and tobacco use, constraints preventing physical activity, salt and sodium intake, and premature mortality from any of these conditions.

It is doubtful these policies will yield expected returns given the state of the Indian health system that has not kept up with the range of challenges fostered by globalization and changing lifestyles. As chronic challenges rage, the government needs to double up on preventive efforts in addition to the range of medical and drug therapies. This would work to reduce the prevalence of conditions that cause diabetes, heart disease, cancer, and related ailments. Critically, this comes down to capacity. 

To enhance the government’s capacity on the problem, it is necessary to institute a government-wide approach, in which other sectors like trade, agriculture, transportation, finance, road, and infrastructure have a say and role in tackling NCDs. To address obesity, for instance, the Ministry of Finance can use taxes and subsidies to encourage healthy diets; the Agriculture Ministry can advance the production and consumption of healthy foods; Consumer Affairs and Food Production Ministry should remedy deficits in food distribution; those responsible with Urban planning can chip in by designing more open spaces to boost physical activity and the Ministry of Information can raise awareness on the benefits of healthy diets and physical activity. Though India’s NCD action plan explicitly states a desire to promote policy coordination, inter-agency policies have not emerged as of yet.

Second, coverage needs to improve. States across the country have to play a greater role. Delhi has to provide more resources to primary care facilities, away from hospital-based care, across the country. Risk factors and conditions are treated at a much earlier period through this approach, lessening the burdens being imposed on tertiary facilities like AIIMS. To be sure, the National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke (NPCDCS) relies on frontline healthcare workers to conduct screening for diabetes and hypertension but this gatekeeping can be bettered.

Third, more robust surveillance practices are needed to better understand the NCD problem and how it is being tackled across the country. Solid information and data can assist the government’s plan and implement targeted prevention and control programs. Also, a database of NCD best practices and interventions, which can be shared by medical and policy practitioners, should be developed. 

The evidence to mount strong interventions against NCDs in India is compelling. A recent Harvard University and World Economic Forum Report on NCDs claimed that India stands to lose $4.5 trillion before 2030 due to the surging problem. But these losses are not preordained. Options exist for policymakers to institute policies aimed at prevention and care. India is well served by a national action plan on NCDs but more work is needed to strengthen the health infrastructure supporting that effort to make meaningful progress against chronic diseases. 

Karthik Nachiappan is a Doctoral Candidate at the India Institute, King’s College London.

India in Transition (IiT) is published by the Center for the Advanced Study of India (CASI) of the University of Pennsylvania and partially funded by the Nand and Jeet Khemka Foundation. All viewpoints, positions, and conclusions expressed in IiT are solely those of the author(s) and not specifically those of CASI and the Khemka Foundation. IiT articles are re-published in the op-ed pages of The Hindu: Business Line. This article can be read here.

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