Elsevier

The Lancet

Volume 377, Issue 9763, 29 January–4 February 2011, Pages 413-428
The Lancet

Series
Chronic diseases and injuries in India

https://doi.org/10.1016/S0140-6736(10)61188-9Get rights and content

Summary

Chronic diseases (eg, cardiovascular diseases, mental health disorders, diabetes, and cancer) and injuries are the leading causes of death and disability in India, and we project pronounced increases in their contribution to the burden of disease during the next 25 years. Most chronic diseases are equally prevalent in poor and rural populations and often occur together. Although a wide range of cost-effective primary and secondary prevention strategies are available, their coverage is generally low, especially in poor and rural populations. Much of the care for chronic diseases and injuries is provided in the private sector and can be very expensive. Sufficient evidence exists to warrant immediate action to scale up interventions for chronic diseases and injuries through private and public sectors; improved public health and primary health-care systems are essential for the implementation of cost-effective interventions. We strongly advocate the need to strengthen social and policy frameworks to enable the implementation of interventions such as taxation on bidis (small hand-rolled cigarettes), smokeless tobacco, and locally brewed alcohols. We also advocate the integration of national programmes for various chronic diseases and injuries with one another and with national health agendas. India has already passed the early stages of a chronic disease and injury epidemic; in view of the implications for future disease burden and the demographic transition that is in progress in India, the rate at which effective prevention and control is implemented should be substantially increased. The emerging agenda of chronic diseases and injuries should be a political priority and central to national consciousness, if universal health care is to be achieved.

Introduction

The first two reports1, 2 in this Series on health care for all in India focused on unfinished priority public health agendas, notably maternal and child health, nutrition, and infectious diseases. In this report, we concentrate on chronic diseases and injuries, which are emerging public health priorities in India. Chronic diseases and injuries are a large and heterogeneous group of disorders and to address them all in this report will not be possible. We therefore focus on and discuss risk factors for diseases and health disorders that account for at least 1% of the national burden of disease.3 On the basis of this burden-of-disease threshold and the availability of cost-effective interventions, we have identified several groups of chronic diseases that often occur together and that have similar health-system interventions. These groups are cardiovascular, respiratory, and metabolic disorders (diabetes, coronary heart disease, stroke, and chronic obstructive pulmonary disease); sensory loss disorders (cataracts, adult-onset hearing loss, and refractory impairments); breast, cervical, and lung cancer; mental health disorders (schizophrenia, depression, and alcohol misuse); and injuries (road traffic injuries and suicides). Some chronic infectious diseases, notably HIV/AIDS, are addressed elsewhere in the Series.1 Therefore, in this report we discuss most of the major chronic diseases and injuries in India.

We try to address two questions. First, what are the current and forecasted burdens of and associated risk factors for chronic diseases and injuries? Second, what are the cost-effective interventions for prevention and treatment of these disorders? A previous Lancet Series drew attention to the burden of chronic diseases and the availability of cost-effective interventions in 23 low-income and middle-income countries.4, 5 We have based our analyses on three WHO data sources (panel 1), and have supplemented these with relevant microstudies or regional data sources when relevant. We then assess the health-system responses to chronic diseases and injuries, and propose actions that need to be implemented to integrate this emerging public health agenda within a health system for the provision of universal health care.

Key messages

  • •

    Chronic diseases (including cardiovascular and respiratory diseases, mental disorders, diabetes, and cancers) and injuries are the leading causes of death and disability in India—their burden will continue to increase during the next 25 years as a consequence of the rapidly ageing population in India.

  • •

    Most chronic diseases are common and often occur as comorbidities.

  • •

    Risk factors for chronic diseases are highly prevalent among the Indian population.

  • •

    Although a wide range of cost-effective prevention strategies are available, implementation is generally low, especially among people who are poor and those living in rural areas.

  • •

    Most health care is provided by the private sector, which often causes high out-of-pocket health expenditure that leads to debt and impoverishment.

  • •

    Immediate action to scale up cost-effective interventions for chronic diseases and injuries is needed; public health-care systems need to be strengthened to allow these interventions to be effectively implemented.

  • •

    Strong public policy commitments to control chronic diseases and injuries need to be implemented more robustly.

Section snippets

Mortality and burden of disease

Of the estimated 10·3 million deaths that occurred in India in 2004, 1·1 million (11%) were due to injuries and 5·2 million (50%) were due to chronic diseases (figure 1; webappendix pp 4–7).3 The chronic diseases discussed in this report caused an estimated 3·6 million (35%) deaths.

Mortality rates for people with age-specific chronic diseases are estimated to be higher in India than in high-income countries. In 2004, the overall age-standardised mortality rates for chronic diseases were 769 per

Burden attributable to risk

Mortality and disease burden attributable to nine risk factors for chronic diseases have been quantified for India by use of the GBD methods for comparative risk assessment.6, 19 Relative risks f or coronary heart disease and stroke mortality associated with total serum cholesterol concentrations were revised on the basis of results of a meta-analysis of 61 cohorts with 900 000 participants from Europe and North America.20 Prevalence distributions for systolic blood pressure, total serum

Projections

We have updated previously reported projections of mortality rates from 2002 to 20303, 7, 24 using the GBD estimates for 2004, projections of deaths associated with HIV/AIDS,25 and forecasts of economic growth by region.26 In India, the number of deaths due to communicable diseases and to maternal, perinatal, and nutritional causes is predicted to decrease between 2004 and 2030 (figure 4).19 As India's population ages during the next 25 years, the total number of deaths will increase

Health behaviours

Our analyses of the World Health Survey data8 show that more than 20% of the Indian population smoke daily. Twice as many people living in rural areas smoke every day compared with the urban population (table 1) and, compared with the richest quintile, about three times as many people in the poorest quintile smoke daily (32·3% vs 11·6%). Data from the Indian Migration Study28 show that men in urban areas are twice as likely to have low physical activity compared with those in rural areas. The

Cost-effectiveness of interventions

We estimated the cost-effectiveness of interventions relating to five categories of disease and injury: cardiovascular and respiratory diseases, sensory loss disorders, mental health disorders, cancer, and road traffic injuries. The cost-effectiveness of intervention strategies for each of these categories is summarised in table 2 (for detailed results, see webappendix pp 11–14). The main data source for these estimates is the WHO-CHOosing Interventions that are Cost Effective (CHOICE) project,

Health system responses

Consensus is increasing among global health policy makers and researchers about the importance of addressing the emerging burden of chronic diseases in low-income and middle-income countries.85 Several principles underpin it: strengthened public health and primary health-care systems are essential; population ageing will increase the absolute numbers of people with chronic diseases; the main causes of the major chronic diseases are well understood and are just as relevant in developing

Policies

India has made substantial progress in development of national policies that are backed by adequate resources to comprehensively address the burden of chronic diseases and injuries (table 3). However, most of these national programmes have been “structured around a technological response and focused on specific targets” rather than having multicomponent interventions,100 and their success has been variable. The National Mental Health Programme, for example, was initiated over a quarter of a

Health care

Heterogeneity is the most striking aspect of the management of patients with chronic diseases and injuries in India: on the one hand some patients receive the best possible evidence-based treatment at tertiary hospitals, but on the other hand, some patients have poor access to basic care and their disorders are usually not detected or adequately treated.105 Despite the substantial burden of chronic diseases and injuries, and the availability of cost-effective interventions, data from the World

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