Combating NCDs effectively

Diabetes is not the only non-communicable disease (NCD) that extracts high costs. The 2013 IHME study estimates that cardiovascular diseases resulted in 2.1 million deaths between 1990 and 2010, chronic respiratory diseases accounted for over 1.1 million, and cancer for over 660,000. The economic cost is also high—the WHO estimates that NCDs cost us $237 billion in lost output during 2006-15. A November 2014 report by the Harvard School of Public Health and the World Economic Forum (WEF) estimates that the cost from NCDs will be as high as $3.55 trillion in output between 2012 and 2030.

The government recognises this burden and has taken action with the launch of the National Programme for the Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). The objective is to target the greatest risk factors contributing to NCDs—unhealthy diet, physical inactivity, tobacco and alcohol use, and air pollution. The government is also committed to improving screening, prevention and treatment of NCDs.

To assess India’s challenges in tackling NCDs—and the government’s strategy in addressing them—comparison with similar economies can throw up interesting insights. Often, we are compared with China. The elephant versus dragon comparison on almost every social and economic indicator has been made—from manufacturing to human resources. One indicator of prime importance is health. Here, China’s case can be instructive. NCDs account for a greater proportion of mortality in China: 83% versus 53% for India. In absolute terms, NCDs cause an estimated 8 million deaths in China and 5 million in India. But China has an older population, and on an age-adjusted basis (since age itself is a factor in NCD mortality), India has a higher NCD death rate overall—heart attacks are more prevalent in India. This raises the question: How effective are NCD-related policies?

That can be assessed on how both countries perform on the WHO-identified set of ‘best buys’—interventions designed to reduce NCD mortality and morbidity—that are highly cost-effective and feasible to implement within the constraints faced by both the countries. Three ‘best-buys’ address risk factors (tobacco use, harmful alcohol use, and unhealthy diet and physical inactivity) and another three focus on medical management (cardiovascular diseases, diabetes and cancer).

China has increased its commitment to NCD control through general policy design and decentralised implementation. There are five policy priorities—the ‘whole of government and whole of society’ approach, healthcare reforms that strengthen primary healthcare, tobacco control, population salt reduction, and promoting translational research (mostly clinical research).

The first national guideline—National Plan for NCD Prevention and Treatment (2012-15)—was issued by 15 ministries and commissions, with three basic principles: (1) multi-sectoral collaboration and facilitating social participation; (2) focus on key priorities, tailor programmes on different localities; and (3) prevention strategies at the core and empowering primary healthcare. As part of healthcare reforms initiated in 2009, primary healthcare providers are capable of managing hypertension patients, helping them to control their blood pressure.

China’s advancements in electronic healthcare record-keeping facilitate the conduct of high quality clinical trials, with greater statistical power. Established bodies like the National Centre for Cardiovascular Diseases (NCCD), with their experience in conducting large-scale trials, have a broad and robust network that includes government institutes, local public health providers and an array of collaborating hospitals become a solid platform for research and implementation of solutions.

With India’s alignment with the WHO’s ‘global action plan for the prevention and control of NCDs 2013-20’, it has been the first country to develop specific national targets and indicators aimed at reducing the number of global premature deaths from NCDs by 25% before the end of 2025. A national, multi-sectoral action plan that outlines actions to be taken by various sectors (in addition to healthcare) to reduce the burden of NCDs and their risk factors is in the final stages of development.

After the NPCDCS pilot in 2008, several state-level plans have been rolled out; the NPCDCS is intended to complement other national programmes. Since health is a state subject, reviewing the efforts of a leading state is appropriate. Tamil Nadu’s Health Systems Strengthening Project is a good example, which increases access to health services for the poor, disadvantaged and elderly people, develops interventions to address NCD challenges, improves health outcomes and service delivery, and increases effectiveness of public sector hospital services.

Key challenges include creating the infrastructure for delivering healthcare services and, more importantly, financing these policy initiatives and efforts. The Twelfth Five-Year Plan (2012-17) envisages $3.1 billion as the outlay for the NPCDCS. Compared to the costs of NCDs in lost economic output at $3.55 trillion from 2013 to 2030, that scale of financial resources is inadequate.

Public financing of healthcare needs to go up substantially. We have been advocating an increase in public health spending from the current, very low 1% of GDP to at least 2.5% of GDP by 2017. In fact, a 2015 IMS health report proposed solutions on increasing healthcare financing, including universal healthcare coverage for vulnerable groups, a combination of public and private insurance for middle-income families, and additional taxes on tobacco and alcohol that should be earmarked for healthcare spending.

Investing in healthcare infrastructure and drawing on lessons for healthcare system reform from countries like Singapore, the UK, Germany and the US is also essential. The combined experience of countries can offer important lessons on sustainable financing and cost containment strategies.

Ultimately, the focus of all healthcare systems should be the patient. Experts highlight that an integrated patient-centric approach with a universal chronic disease management framework is the need of the hour. Restructuring and strengthening of healthcare systems has resulted in a commendable decline in the incidence rate of infectious diseases, providing adequate proof that the same is possible for NCDs. Sustained efforts by relevant stakeholder groups across the country are crucial to accomplish the India NCD goals set for 2025 by the government. We need to ACT (Awareness, Capacity building and Treatment) now.

The author is director general, Organisation of Pharmaceutical Producers of India