Mareike Kroll & Frauke Kraas
University of Cologne, Germany
Non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, pose an increasing public health challenge in urban India, especially due to changes in lifestyles, behaviours and the physical and social environments in cities. NCDs are likely to increase intra-urban health disparities and have a negative impact on poverty alleviation. The Indian government has begun to address this challenge; however, building awareness of NCDs in the general public, improving the response of the health system, and the need for a solid database for evaluating progress remain important challenges.
The global challenge of non-communicable diseases
Non-communicable diseases (NCDs) are chronic conditions that progress slowly and are rarely completely curable. The increasing NCD is one of the most pressing global public health challenges (UN, 2012), with NCDs accounting for 63% of all global deaths worldwide (WHO/UN-Habitat, 2016). The four most common NCDs – cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes – are mainly caused by preventable behavioural risk factors, such as tobacco and alcohol consumption, unhealthy diet, and insufficient physical exercise (WHO, 2011c). While the NCD mortality rate in the European Region is estimated to remain constant, the rate in South-East Asia, Africa, and the Eastern Mediterranean will continue to increase (WHO, 2011c).
NCDs in urban India
In India, NCDs contributed to an estimated 61% of all deaths in 2014 (WHO, 2014) (graph 1). Projections indicate that rate will rise to 67% by 2030 (Mohan et al., 2011). Furthermore, NCDs impact people at younger ages at a higher rate when compared to high-income countries, increasing the healthy life years lost and the risk of premature death. About 29% of NCD-related deaths in low- and middle-income countries occur among people under the age of 60, compared to 13% in high-income countries (WHO/UN-Habitat, 2016).
Although NCDs are on the rise among the entire Indian population, the incidence of diabetes and cardiovascular diseases is especially higher in cities (Mohan et al., 2008; Ramachandran & Snehalatha, 2009; Gupta & Ahuja, 2010). However, data on NCD mortality and morbidity as well as the most common risk factors for NCDs is inadequate (World Bank, 2011; Raban et al., 2012; Mohan et al., 2012). Existing data is often not disaggregated according to cities or intra-urban population subgroups. Only estimates from different studies exist for some cities. For example, the prevalence of coronary heart disease in urban areas varies between 7% and 13%, and for diabetes between 5% and 15% (Rajan & Prabhakaran, 2012). The increase of NCDs, especially in urban India, is contributing to an epidemiological transition. However, the burden of communicable diseases such as gastrointestinal and respiratory diseases is still high (Rajan & Prabhakaran, 2012; Kroll et al., 2014), and poses a challenge for urban health.
Urbanization as driver for NCDs and major challenges
The increase of NCDs in India is accelerated by an aging population and driven by rapid and unplanned urbanization as well as lifestyles changes. Though NCDs are not confined to cities, urban environments can exacerbate lifestyles and behaviours that can act as risk factors (WHO/UN-Habitat, 2016), such as altered working conditions, increased pace of life, socioeconomic uncertainties, and/or modifications in dietary patterns. Urbanization is also leading to alterations in the physical environment, with an increase in environmental stressors such as air pollution, heat waves, and noise. With the urban population estimated to grow by 404 million people between 2014 and 2050 (UN, 2014), living conditions in cities will become even more crucial for public health.
Health care in India is mainly financed by out of pocket expenditure. NCDs have a huge socioeconomic impact due to required long-term treatments, which is particularly difficult to bear for the urban poor and can have a negative impact on poverty alleviation (Rajan & Prabhakaran, 2012). For India alone, the costs incurred by the treatment of cardiovascular diseases, diabetes, cancer, chronic respiratory diseases and mental health disorders between 2012 and 2030 have been estimated at US$6.2 trillion (WHO/UN-Habitat 2016). If not adequately treated, people with NCDs are at a higher risk to develop comorbidities (e.g., diabetic foot, organ damage) and communicable diseases. For example, diabetes is a known risk factor for tuberculosis and HIV/AIDS (Gupta et al., 2011; WHO, 2011a). Therefore, the increasing prevalence of NCDs also jeopardizes communicable disease prevention and control (WHO/UN-Habitat, 2016). The high burden of NCDs also aggravates the already overloaded public health care system, which will require reorientation to address these newer challenges through referrals, follow-up systems, and clinical guidelines for NCD treatment (Mohan et al., 2012).
Rising intra-urban health disparities In India
A recent report by the WHO and UN-Habitat (2016: 33) reaffirms that “urban health equity remains a persistent, priority global health issue”. The health status of the urban poor in India is not only worse compared to the urban affluent, but often even worse than those who live in the countryside. For example, malnutrition for urban-dwelling children under five in the poorest quintile was 56% in 2005, compared to 40% (urban average) and 51% (countryside) (WHO, 2016). This “health divide” (WHO/UN-Habitat, 2010) is caused by variations in nutritional intake and by disparities in living conditions (photo 1). It results in differences in exposure to risk factors and protective factors of the physical and social environment (susceptibility) resulting in unequal morbidity and mortality patterns (graph 2).
While NCDs were considered a major problem of the affluent for a long time, recent studies report a reversal of the gradient, e.g., in cardiovascular disease and diabetes and its risk factors (Rajan & Prabhakaran, 2012). A study on health disparities in Pune (Kroll, 2013; Kroll et al., 2014) observed a slightly higher prevalence of diabetes and hypertension among higher socioeconomic groups, but a higher incidence and more frequent complications and comorbidities in lower socioeconomic groups. This indicates that disparities also as the occurrence of comorbidities due to differences in risk factor exposure, health knowledge, health action (preventive), and disease action (curative) (graph 2).
For example, only 12% of the general population is aware of diabetes risk factors, and only 41% of diabetics of the risk of comorbidities, i.e., organ damage (Rajan & Prabhakaran, 2012). Lack of health knowledge is leading to lack of health action (e.g., in respect to diet or physical activity) and can also result in inadequate health seeking behavior (i.e., disease action) due to several reasons: Although urban health systems are often regarded as an asset, not all urban dwellers have access to available healthcare facilities (MoHFW, 2013; Butsch, 2011; Butsch et al., 2015). Whereas the public health care sector, which offers subsidized care, is highly overburdened, the urban poor and even the middle class cannot afford to pay for health check-ups and long-term treatment. Due to high fragmentation and lack of organisation in the private health care sector (Garg & Nagpal, 2014; Baru, 2013) (images 2 & 3), the urban poor are at the highest risk to receive inadequate care from unqualified health care providers, or are not able to understand and follow the treatment plan.
Fighting non-communicable diseases in India
Given their devastating health and socioeconomic effects, NCDs have gained increasing attention over the past decade in the international community (UN, 2012; WHO, 2013). The WHO (2013: 4) has identified six objectives to fight NCDs:
- raising priority on prevention and control,
- strengthening national capacity for NCD control,
- reducing modifiable risk factors,
- strengthening health systems,
- promoting research; and
- monitoring the trends and determinants of NCDs and evaluating progress in prevention and control.
Evidence from high-income countries indicates that interventions for most NCDs can be effective and implemented at a rather low cost (WHO, 2011b). The Indian Ministry of Health and Family Welfare addresses the increasing burden of NCDs through various programs (Mohan et al., 2012). Launched in 2010, The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) focuses on the prevention and control NCDs through behavioural and lifestyle changes and early diagnosis and management of NCDs (Krishnan et al., 2011; MoHFW, 2009 & 2016). Recognizing its past neglect of urban health, the Indian government also launched the National Urban Health Mission (NUHM) in 2013.
Its main objective is to improve the health status of the urban poor through improved access to health care facilities including outreach services, screening for NCDs at primary care level and referral to secondary and tertiary level, and empowerment and awareness generation to change health action and health seeking behaviour (MoHFW, 2013).
The frameworks of these programs aim in the right direction, the impacts of implementation must be evaluated in the future. The long-term nature and complex disease aetiology of NCDs demands a comprehensive and long-term health system-mediated response. Accurate and sequential data for planning and evaluation through disease surveillance is essential to this goal.
The need for better disease surveillance
The objective of disease surveillance is to address a defined public health problem and to develop evidence-based measures to protect and promote population health (Hall et al., 2012) (graph 3).
Despite the increasing impact of NCDs on public health in India, lack of good quality data hampers the planning process for NCD prevention and control (World Bank, 2011; Kroll et al., 2015). The focus in India has so far been on surveillance of communicable diseases, such as malaria, dengue and tuberculosis. As well, data is mainly collected from public health care facilities despite the dominant role of the private health care sector in cities. Health programs that focus on NCDs have weak surveillance components. Against this background, we conducted a knowledge-attitude-practice-survey on disease surveillance among private practitioners in Pune (Phalkey et al., 2015), followed by a six-months test run for an NCD sentinel surveillance system among 127 private practitioners (results will be published elsewhere). Preliminary results show that, if certain barriers are addressed, inclusion of private practitioners in NCD sentinel surveillance is possible.
In light of the increasing burden of NCDs, the risk of comorbidities, and the long term socioeconomic impacts in India, capacities for NCD surveillance must be strengthened to facilitate evidence-based decision-making, to evaluate the success of existing public health programs, and to identify upcoming health challenges. Building awareness about NCD risk factors, NCD management, and the improvement of living conditions in cities, i.e., improving socioeconomic conditions of the urban poor, making cities more walkable, and providing recreational space to encourage healthy behaviour are important prerequisites. This requires the right mixture of multi-sectoral small scale and large scale interventions for health promotion and NCD control through early detection and treatment.
Header Image: Mother and daughter walking in Pune, India. Image Credit: Adam Cohn / flickr.com