Nations within a Nation: Variations in Epidemiological Transition across the States of India, 1990–2016 in the Global Burden of Disease StudyARTICLE
India State-Level Disease Burden Initiative Collaborators. Nations within a nation: Variations in epidemiological transition across the states of India, 1990-2016 in the Global Burden of Disease Study.
Lancet. 2017;390:2437-60.
“We inhabit a universe that is characterized by diversity”
– Desmond Tutu
COMMENT
The age-standardized Disability-adjusted life-year (DALY) rate in India has dropped by 36% from 1990 to 2016, indicating overall progress in reducing disease burden. Nonetheless, there are huge variations in the magnitude and progress across the states of India for the various diseases and risk factors. The state-level disease burden and risk factor estimates can serve as a crucial aid in this health planning approach suggested by the government. The India State-Level Disease Burden Initiative policy report, released on November 14, 2017, provides detailed findings, including a profile of each state. India's 2017 National Health Policy has set out a series of disease-reduction targets. Monitoring the trends across the states with robust findings is crucial to understand where more effort is needed to meet the national targets.
The epidemiological transition ratio [DALYs due to CMNNDs vs. non-communicable diseases (NCDs) and injuries combined] ranged from 0.16 for Kerala to 0.74 for Bihar in 2016, a greater than four-time difference. The transition of disease epidemiology in India towards a dominance of NCDs and injuries from 1990 to 2016 is remarkable. Non-communicable diseases and injuries became the majority of overall disease burden for India in 2003; but this event occurred from 1986 to 2010 for the four ETL state groups. The epidemiological transition ratio had a significant inverse relation with sustainable development index (SDI), but the slope of this association had reduced by about half from 1990 to 2016, indicating reducing differences with increasing SDI over time. Although the burden of CMNNDs has dropped substantially across all ETL state groups in India from 1990 to 2016, the ratio of the observed to expected DALY rate for the SDI level of India is quite high for most of these diseases, indicating that India suffers a disproportionately higher burden of these diseases than other parts of the world with similar SDIs. The high neonatal and under-5 disease burden, predominantly due to the leading CMNNDs, continues to be a major priority for India. Intensive efforts to reduce this burden are necessary to meet the Sustainable targets in 2030. India has adopted the Newborn Action Plan, which is in synchrony with the Global Every Newborn Action Plan, focusing on 187 priority districts.
Child and maternal malnutrition continues to be the leading risk factor in India, responsible for 15% of total DALYs in 2016; and unsafe water, sanitation, and hand washing still causes 5% of total DALYs in India. This trend continues despite major programme in India for several decades to address these risk factors. The government program Integrated Child Development Services was launched in 1975 to provide supplementary nutrition, nutrition and health education, and other preschool development services. The Midday Meal Scheme in 1995, to provide free lunch to primary and upper primary school children. The National Food Security Act in 2013, to provide food and nutritional security to citizens through provision of subsidized food grains and focused nutritional support to women and children. The Rural Sanitation Programme in 1986, currently elaborated as the Clean India Mission (Swachh Bharat Abhiyan), in 2014 to clean India and 3eliminate open defecation. Notably, the burden of these risk factors continues to be the highest in the states with lower ETLs, with Bihar having the highest DALY rate in India due to child and maternal malnutrition and Jharkhand due to unsafe water, sanitation, and hand-washing. An important challenge that needs to be addressed for a higher impact of interventions is efforts at behavioral change along with provision of better nutrition, safe water, and safe sanitation for those who need these most.
India has the highest tuberculosis burden in the world, with a DALY rate more than three times higher than can be explained by its SDI level. India has scaled up basic tuberculosis services in the public health system, but the rate of decline in tuberculosis seems too slow to meet the 2030 Sustainable Development Goals and the 2035 End TB targets. Major challenges have been delayed detection and treatment of tuberculosis, inadequate surveillance, poor notification, and absence of coordination with the private health-care sector. A National Strategic Plan for Tuberculosis Elimination was announced in 2017 by India's Revised National Tuberculosis Control Programme to achieve a 10–15% annual decline in the incidence of tuberculosis costing US$2.5 billion over 5 years. Control or elimination of malaria and some neglected tropical diseases, including visceral leishmaniasis, lymphatic filariasis, and leprosy have also been specified by the National Healthy Policy 2017 and NITI Aayog action agenda as priorities.
The all-age prevalence of most leading NCDs increased substantially in India from 1990 to 2016, but the age-standardized prevalence increased only for diabetes, cerebrovascular disease, ischemic heart disease, and skin diseases. This trend implies that the overall increase in NCD prevalence in India is a mixed phenomenon, for increased prevalence of many NCDs due to aging population and changes in risk exposure for diseases having an age-standardized increase in prevalence. In 2016, the observed DALY rate in India exceeded the rate expected for its SDI level for several leading NCDs. Tobacco use contributed 6% of DALYs in India in 2016. The Government of India enacted the Cigarettes and Other Tobacco Products Act in 2003 to discourage the use of tobacco products, and the National Tobacco Control Programme was launched in 2007. The National Mental Health Programme launched in 1982, and the Mental Health Care Act was enacted in 2017. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke was launched in India in 2010. These efforts would have to include extensive intersectoral collaborations, because many of the interventions needed for the control of NCDs go beyond the traditional health sector.
Disease burden for exposure to air pollution is highest in the low ETL state group, with Rajasthan, Uttar Pradesh, and Bihar having the highest DALY rates. The burden from household air pollution is declining for decreasing use of solid fuels for cooking. However, this decline was least in the low ETL group. A recent initiative, the Pradhan Mantri Ujjwala Yojna, is expected to further increase access to clean cooking gas for households those are below the poverty line. However, ambient air pollution by emissions and dust from the power, industrial, transport, and construction sectors continues to pose substantial challenges across all ETL state groups. Policies are needed that increase the use of technologies with less emissions and dust.
The number of DALYs caused by injuries increased significantly from 1990 to 2016; however, injuries get very little attention from policy makers and researchers in India. India does not have a comprehensive policy for injury prevention as well as multisectoral interventions needed for the control of injuries is not addressed adequately. A National Road Safety Policy under the Ministry of Road Transport and Highways was announced in 2010. The National Highways Authority of India announced plans in 2017 to provide more prompt trauma care on highways. Prevention of falls and adequate management requires a systematic effort in India that currently does not exist.
Two factors that will pose major challenges to the Indian health system over the next few decades are unplanned urbanization and ageing of the population. India does not have an adequately 4functional cause-of-death reporting system. The Medical Certification of Cause of Death system under the Office of the Registrar General of India covered only 22% of the deaths in India in 2015. Sample Registration System provide cause-of-death data for all states in India using verbal autopsy. Verbal autopsy is considered a reasonable alternative for cause-of-death data when these data are not adequately available from the vital registration system. India needs to systematically develop a comprehensive health information system that can provide adequate data for ongoing and reliable mortality, morbidity, and risk factor estimation at suitable levels of geographic disaggregation, a notion supported by both the recent NITI Aayog action agenda and the National Health Policy.
In conclusion, this analysis of epidemiological transition, disease burden, and risk factors across the states of India from 1990 to 2016 is perhaps the most comprehensive attempt so far to understand the entire landscape of disease epidemiology in India. The ongoing work of the India State-Level Disease Burden Initiative could be a useful tool for NITI Aayog's recently articulated vision of transforming health services and health outcomes in India over the next 15 years and for tracking progress in the goals and targets set by the National Health Policy 2017. To achieve its optimal development potential, India should improve the health and nutritional status of its people in earnest now, investing more resources in social sectors as a result of its continuing impressive economic progress and using the increasing understanding of health heterogeneity across the country in a manner that reduces the major health inequalities between the nations within this nation, which comprises almost a fifth of the world's population.