NCMH Background Papers—Burden of Disease in India
Disease burden in India: Estimations and causal analysis
Disease burden in India
Estimations and causal analysis*
Disease burden estimations based on sound epidemiological
research provide the foundation for public policy. Which
diseases and what interventions does public policy need to
focus upon are normally derived from such evidence. Well
researched, longitudinal data can enable judicious targeting
and help decide what needs to be done where, for whom,
and when. Conversely, the absence of such good quality
empirical data can affect programme designing and consequently
outcomes. India has ample evidence of such
impacts, often due to the mismatch between disease burden
and its causal factors, and the interventions adopted and
priorities in resource allocation.
Besides the need to avert disease for enhancing the quality
of life, neglect can have adverse consequences on the wellbeing
of affected families—social, psychological as well as
economic. Diseases that are heavily concentrated among
working age adults or the poor, as is the case with HIV/
AIDS, cardiovascular disease (CVD), tuberculosis (TB), etc.,
can have a ruinous impact as such diseases are extremely
expensive to treat, especially due to lack of insurance
mechanisms. For example, in the case of HIV/AIDS, the
The Term Paper on How was the Gupta Empire (India) scientifically advanced
When thinking back to the Gupta Empire in India, one might remember the famous works of literature, or perhaps the vast lands conquered by the great rulers of the time. But it would be imprudent to ignore the influential achievements made in the areas of science, medicine, mathematics, and astronomy that made the empire scientifically advanced. Many people fail to realize that countless things ...
out-of-pocket expenditure on treatment and services was
reportedly Rs 6000 per HIV-positive person over a six-month
reference period, while for clients on antiretroviral treatment
(ART), the expenditures were markedly higher, nearly
Rs 18,150 per person over a six-month period. Roughly
40%–70% of these expenditures are financed by borrowing.
The devastating impact of TB, asthma, chronic obstructive
pulmonary disease (COPD), heart diseases, etc. on individual
household is similar, with children having to discontinue
schooling and/or take up employment to provide an additional
source of income. Analysis of data from the 1995–
96 survey round of the National Sample Survey (NSS)
undertaken by the National Commission on Macroeconomics
and Health (NCMH) suggests that the out-of-pocket expenditure
by individuals hospitalized on account of heart disease
was roughly Rs 11,000 per person, or 120% of the average
annual per capita expenditure of the households they
belonged to. Likewise, roughly Rs 32,000 is the annual cost
of treatment for acute cases of COPD that involve hospitalization.
Therefore, it is clear that the onset of disease needs
to be averted and when it occurs it should be treated quickly.
For policies to ensure this, it is necessary that we have an
evidence-based understanding of the extent of disease
burden, the population groups that are the most vulnerable,
and what interventions are needed to avert premature death
or needless suffering.
With the above objectives in mind, the NCMH undertook
an exercise to (i) identify major health conditions in terms
of their contribution to India’s disease burden; (ii) estimate
the incidence and prevalence levels of the diseases/conditions
at present and in 2015; (iii) list the causal factors underlying
the spread of the diseases/conditions; (iv) suggest, based on
the available evidence, the most cost-effective and lowcost
solutions/strategies, both preventive and curative, for
reducing the disease burden, particularly among the poor;
The Review on Infant and Child Illegal Immigrants: Consequences of Having No Health Care
Introduction In many states, the concerned localities and the local government are considered responsible for the medical care and expense of indigent people. Among the documented needy population sprouts an increasing number of alien persons who exist among the medically underserved community. Studies attempting to determine the exact health needs of a certain population discovered that a hefty ...
and (v) indicate what interventions should be provided
where and by whom. For assisting us in this onerous task,
the help of leading experts was taken.
The experts identified 17 priority health conditions (Table 1)
which they felt to be significant public health problems,
affecting all segments of the population. Identification of
these conditions was based on three criteria: first, the
likelihood of the burden of a specific health condition falling
on the poor, such as infectious and vector-borne conditions,
TB and many maternal and child health conditions; second,
in the absence of interventions, the probability of a listed
health condition continuing to impose a serious health
burden on the Indian population in the future, say by 2015,
such as cancers, cardiovascular conditions and diabetes, or
new infections such as HIV/AIDS; and third, the possibility
of a health condition driving a sufficiently large number of
people into financial hardship, including their falling below
the poverty line.
*This overview is based on a paper entitled ‘Choosing Investments in Health’ prepared by Dr Ajay Mahal, Assistant Professor, Harvard School of
Public Health, USA, for the National Commission on Macroeconomics and Health.
NCMH Background Papers—Burden of Disease in India
Disease burden in India: Estimations and causal analysis
Baseline estimates and projections of priority
health conditions
Exhaustive review of the available literature brought forth
two factors of critical importance to public policy: (a) for
almost all diseases/conditions identified, and more particularly
the National Health Programmes in which government
investment was substantial, namely, malaria and other
vector-borne diseases, TB, leprosy, reproductive health and
The Term Paper on Hypnotherapy for Medical Conditions and Health
I've been asked to choose a medical condition, that I find interesting and research it. I've also been asked to show the possible use of hypnotherapy in the treatment of the condition. Introduction I have chosen cancer as a medical condition, which I have an interest in. I will explain what cancer is, the symptoms of the disease and treatments. I will go on to explain further chronic diseases the ...
childhood conditions, there is a paucity of high-quality
epidemiological information and validated data for arriving
at any baseline estimations on prevalence or incidence. In
the absence of operational research there was also weak
evidence regarding the type of interventions that would be
most cost-effective in the different settings in the country;
and (b) a literature review threw up evidence of a large
number of diseases which were considered to be lifestylerelated
and affecting the rich were seen to be affecting the
poor as well, and increasingly so. The non-availability of
good quality data has been a major handicap in arriving
at reliable estimations of the disease burden, affecting our
ability to formulate appropriate policies and provide
adequate budgets.
Category I: Communicable diseases, maternal and child
health conditions
Category I health conditions include HIV, TB, malaria,
diarrhoea, acute respiratory infections, maternal and
perinatal conditions (Fig. 1).
These accounted for nearly
half of India’s disease burden in 1998. It is expected that
the burden on account of most of these pre-transition
diseases, and deaths on account of malaria, TB, diarrhoea
and other infectious diseases will reduce and leprosy be
eliminated. However, HIV/AIDS and opportunistic infections
such as TB and drug-resistant malaria are likely
to increase. It is estimated that currently there are 51 lakh
adults with HIV (adults being defined as the age group of
15–49 years for this purpose), a little less than 1% of the
total population in this age group (Kumar et al., unpublished).
A conservative set of projections suggests that an
estimated 3% of people in the age group of 15–49 years,
i.e. about 5 crore people, are likely to be HIV-positive by
the year 2025; and around 1.5–1.8 crore by 2015 (Kumar
The Term Paper on Suicide Awareness Condition Or General Health Topic
Suicide Awareness Suicide ranks as a leading cause of death but by knowing and understanding symptoms and causes suicide can be prevented. Suicide is an intentional attempt to kill oneself whether it is successful or unsuccessful. Suicide accounts for about one percent of all deaths in the United States each year (Disease, Condition or General Health Topic). During the last two decades suicide ...
et al., unpublished).
These huge numbers of people with
HIV at any given point in time do not, of course, include
people who may have previously died of AIDS-related
causes, and thus only a partial picture is available of the
ARI
TB
HIV infection
Malaria+
Diarrhoea
19% 18%
6%
4%
3%
16%
11%
6%
17%
Childhood illness
Maternal illness
Perinatal illness
Others
Fig. 1 Priority communicable maternal and child health conditions in India, by
share in the burden of disease, 1998
ARI: acute respiratory infection; TB: tuberculosis; HIV: human immunodeficiency
virus
Source: Peters et al. 2001
Table 1. Health conditions and disability-adjusted life-years (DALYs) lost
in India, 1998
Share in the
total burden
DALYs lost of disease
Disease/health condition ( x 1000) (%)
Communicable diseases, maternal and
perinatal conditions
Tuberculosis 7,577 2.8
HIV/AIDS 5,611 2.1
Diarrhoeal diseases 22,005 8.2
Malaria and other vector-borne conditions 4,200 1.6
Leprosy 208 0.1
Childhood diseases 14,463 5.4
Otitis media 475 0.1
Maternal and perinatal conditions 31,207 11.6
Others 49,517 18.4
Non-communicable conditions
Cancers 8,992 3.4
Diabetes 1,981 0.7
Mental illness 22,944 8.5
Blindness 3,699 1.4
Cardiovascular diseases 26,932 10.0
COPD and asthma 4,061 1.5
Oral diseases 1,247 0.5
Others 18,801 7.0
Injuries 45,032 16.7
All listed conditions 200,634 74.6
Others 68,319 25.4
COPD: chronic obstructive pulmonary disease
Source: Peters et al. 2001
NCMH Background Papers—Burden of Disease in India
Disease burden in India: Estimations and causal analysis
cumulative future disease burden from HIV/AIDS. Due to
lack of data and information, projection of the incidence
of TB on account of a rising number of HIV/AIDS cases
has not been possible.
The Essay on Lifestyle Diseases 2
... two years stated that in June the previous year, Pacific health ministers had declared a non-communicable disease ( ... arose from 16percent to percent. Urbanization creates conditions in which people are exposed to new ... There are many diseases that contribute immensely to the burden placed on a person, ... Student Health Survey, current tobacco use among males in this group is 29pecent in India, 21percent ...
Nearly 40% of the Indian population of all ages has
Mycobacterium tuberculosis infection; and there are about
85 lakh people with TB at any given time. With more than
400,000 dying each year (Yajnik et al. 2002; Tuberculosis
Research Centre [TRC] 2004),TB is the single most important
cause of death in India at present (Yajnik et al. 2002).
Maternal, perinatal and childhood conditions account
for another significant percentage of the disease burden, of
particular importance for the poor. Although no direct
estimates of the prevalence/incidence of these health conditions
are available, we can indirectly assess their importance
by looking at the neonatal, infant, under-5 and maternal
mortality rates, which continue to be unacceptably high.
While IMR was estimated to be about 66 per 1000 livebirths,
the under-5 mortality rate was estimated at 95 per
1000 live-births in 1998–99 as per the National Family
Health Survey. The maternal mortality ratio (MMR) was
estimated at 440 per 100,000 live-births in 1992–96. While
no projections are available for MMR, a simplistic set of
projections assume that rates of decline in the infant and
under-5 mortality would be 46 and 62, respectively by the
year 2015, lesser than the goals laid down under the
Millennium Declaration. These forecasts are, however, not
reliable as these ignore trends in and interplay with factors
that underlie changes in the rates of infant, under-5 and
maternal mortality (Deolalikar, forthcoming).
Malaria, dengue and other vector-borne conditions were
estimated to account for 1.6% of India’s total disease burden
(WHO 1998).
Unfortunately, these estimations lack credibility
as reliable population-based data on these conditions do
not exist in India. With most information ‘reported’ by
officials, there are strong reasons to suspect underreporting
and incomplete reporting of data. Underreporting occurs
when a large number of patients visit private health care
providers who are under no obligation to report cases to
The Term Paper on Infectious Disease and Health Protection Agency
The guidance is divided into sections as follows: Section 1Introduces infection control and explains notification; Section 2deals with general infection control procedures; Section 3gives guidance on the management of outbreaks; Section 4describes specific infectious diseases; Section 5contact numbers and sources of information; Section 6contains additional detailed information and a table of ...
the public health authorities, and when record-keeping and
case-finding are done by poorly monitored employees who
may receive incentives for underreporting to demonstrate
the success of a programme. Household survey methods
are also not very useful to fill any gaps in this regard since
many of these diseases, especially malaria, are likely to get
recorded as ‘unspecified fevers’.
Category II: Non-communicable conditions
This category of health conditions accounts for the secondlargest
share, after communicable health conditions, of
the disease burden in India and includes cancers, CVD,
diabetes, respiratory conditions such as asthma and COPD,
and mental health disorders (Fig. 2).
Available data suggest
that these conditions will account for a fairly sharp increase
in India’s disease burden in the future.
Cardiovascular disease
According to recent estimates, cases of CVD may increase
from about 2.9 crore in 2000 to as many as 6.4 crore in
2015, and the number of deaths from CVD will also more
than double. Most of this increase will occur on account
of coronary heart disease—a mix of conditions that includes
acute myocardial infarction, angina pectoris, congestive
heart failure and inflammatory heart disease, although
these are not necessarily mutually exclusive terms. Data
also suggest that although the prevalence rates of CVD in
rural populations will remain lower than that of urban
populations, they will continue to increase, reaching around
13.5% of the rural population in the age group of 60–69
years by 2015. The prevalence rates among younger adults
(age group of 40 years and above) are also likely to increase;
and the prevalence rates among women will keep pace
with those of men across all age groups.
Diabetes
Diabetes is also associated with an increased risk for CVD,
and is emerging as a serious health challenge in India.
Even though it accounted for only about 0.7% of India’s
disease burden in 1998, data suggest a significant load of
diabetes cases in India—rising from 2.6 crore in 2000 to
approximately 4.6 crore by 2015, and particularly concentrated
in the urban population. The data also reveal that
26%
4%
31%
5%
1%
21%
10%
2%
Cancers
Diabetes
Mental health disorders
Blindness
Cardiovascular disease
COPD and asthma
Oral diseases
Others
Fig. 2 Priority non-communicable health conditions in India, by share in the
burden of disease, 1998
COPD: chronic obstructive pulmonary disease
Source: Peters et al. 2001
NCMH Background Papers—Burden of Disease in India
Disease burden in India: Estimations and causal analysis
the prevalence of diabetes is significant even among the
30–39 years’ age group (6%), rising sharply to 13% in the
40–49 years’ age group, and to nearly one-fifth of the
population of those 70 years and above. Moreover, its
prevalence among women above the age of 40 years is high.
Cancers
Cancers are a third area of concern. They refer to a group
of diseases associated with uncontrolled cell growth that
can affect normal body functions, often with fatal outcomes.
Worldwide, cancers account for about 5.1% of the
disease burden and 12.5% of all deaths. In India, cancers
account for about 3.3% of the disease burden and about
9% of all deaths. These estimates will, however, change as
many of the common risk factors for cancers, such as
tobacco and alcohol consumption, continue to become
more prevalent in India. Fairly conservative assumptions
show that the number of people living with cancers will
rise by nearly one-quarter from 2001 to 2016. Nearly 10
lakh new cases of cancer will be diagnosed in 2016,
compared to about 800,000 in 2001. The incidence of
cancers common to both men and women will also see a
sharp increase during this period; nearly 670,000 people
are expected to die of cancer in India in 2016.
Mental health disorders
Mental health was a much neglected field until recently.
There is, however, increasing realization that conditions
such as schizophrenia, mood disorders (bipolar, manic,
depressive and persistent mood disorders) and mental
retardation can impose a marked disease burden on Indians.
This was confirmed by a study conducted for the NCMH
which stated that at least 6.5% of the Indian population
had some form of serious mental disorder, with no discernible
rural–urban differences; women had slightly higher
rates of mental disorder than men. If one were to include
some other ‘common’ mental disorders and alcohol and
drug dependency, the estimates would be substantially
higher. With the increasing size of the population, these
numbers are expected to grow substantially by 2015; the
population with serious disorders is expected to grow to
more than 8 crore in that year, and even higher if the
category of ‘common mental disorders’ in the population
was included in the projections.
Asthma and COPD
Estimates and projections for COPD and asthma show an
equally alarming picture. COPD refers to a group of
disorders that are persistent and largely irreversible, such
as chronic bronchitis and emphysema. It is associated with
an abnormal inflammatory response of the lungs to noxious
particles or gases, especially tobacco smoke and air pollution—
both indoor and outdoor. Asthma is a chronic disease
of the airways, characterized by sudden attacks of laboured
breathing, chest constriction and coughing. Although
asthma can occur at all ages, in about half of the cases it
occurs before the age of 10 years. It is estimated that there
are around 1.49 crore chronic cases of COPD in India in
the age group of 30 years and above, and these are projected
to increase by nearly 50% by the year 2016, including
‘severe’ cases, some of whom may require greater levels of
care, including hospitalization. It is also estimated that
there were roughly 2.5 crore cases of asthma in 2001 which
may increase by nearly 50% by 2016.
Blindness
Data on the current prevalence and future projections for
blindness show that the number of blindness cases is
expected to remain more or less the same during the next
two decades. The projection, however, is based on extremely
optimistic projections on cataract treatment that may not
be realized.
Oral and dental diseases
Available data on the current prevalence and future
projections for oral health conditions suggest an increase
by 25% over the next decade.
These data, together with other evidence presented
previously on non-communicable diseases, suggest a major
future health policy challenge for India. With the continuing
burden of communicable conditions, India is in the classic
bind of facing a ‘dual’ burden of disease.
Category III: Accidents and injuries
The third category of health conditions has a significant
impact on the overall disease burden. It is estimated that
around 9% of the global mortality and 12% of the global
disease burden is due to injuries, intentional or unintentional
(WHO 2004).
Unintentional injuries include road traffic
injuries, poisoning, drowning, falls, etc.; whereas intentional
injuries include suicide, homicide and war-related violence.
Analysis suggests that the share of injuries and accidents
in India’s disease burden may be even greater, at about 16.7%.
It is estimated that the number of deaths from accidents
and injuries in 2005 would range from 730,000 to 985,000,
with projections that deaths from injuries will increase by
as much as 25% over the next decade. The injury mortality
estimates for the year 2000 suggest that about 9% of all
deaths in India were accounted for by injuries, a share
similar to the global share of deaths due to injuries (WHO
2004).
These estimates do not include the health impact of
injuries with non-fatal outcomes (including permanent
disability), which tend to be heavily underreported in India
and could well be in the region of about 5 crore cases per
year. Available evidence from India also shows that much
of the mortality from injuries due to road traffic accidents,
occupational accidents and suicide is concentrated among
NCMH Background Papers—Burden of Disease in India
Disease burden in India: Estimations and causal analysis
adults in their peak work ages, i.e. 15–44 years, and among
children.
Identifying cost-effective interventions
A summary of causal analyses of different diseases/health
conditions carried out by experts engaged by the NCMH
is given in Annexure A. In most cases, disease occurrence
and progression can be avoided or significantly reduced/
contained if access to right information and/or early
treatment is assured.
In countries such as India where there are limited
resources and competing demands, not all conditions can
be treated and not every intervention provided at public
expense. At some point prioritization of interventions or
population groups that need to be supported with public
funding becomes inevitable. The issue then arises as to the
criteria that ought to be used for identifying such publicly
supported interventions. There could be two:
• those that are technically effective in substantially
ameliorating a major health problem; and
• those that are financially inexpensive (i.e. cost-effective)
relative to the outcome gains achieved.
The first ensures that the intervention markedly reduces
the burden of disease, and does not simply result in a token
improvement in the health status. The second ensures that
the intervention is good value for money. Thus, policymakers
can focus on several extremely cost-beneficial and
cost-effective interventions that simultaneously yield large
gains in outcomes for several major health conditions.
While the probability of death beyond a certain age, say
70 years, tends to be high and is not very dissimilar across
developed and developing nations, the largest gains in
mortality reduction are likely to be achieved at younger
ages. Jha and Nguyen (2001) show that whereas 18% of
all Indians can expect to die before the age of 40 years, only
2% of residents of the UK expect to do so. A less marked
difference exists in ‘middle age’, with 51% of all Indians
expecting to die before the age of 70 years compared to
23% for residents of the UK. An understanding of why
these differences exist at younger ages offers the possibility
of identifying cost-effective interventions, particularly
among children and younger adults.
In the case of childhood diseases, India presents wide
regional disparities—while in Kerala, the IMR is 14 per
1000 live-births, it is 96 in Orissa and 5 more States have
an IMR of more than 75 (Deolalikar, forthcoming).
Given
Bangladesh’s rapid advances in recent years, large reductions
in the IMR appear feasible even within resource-poor
settings as in India. If India could achieve an IMR of about
26 per 1000 live-births as implied by the MDGs (double
the rate achieved by Kerala), it could enable India to avoid
nearly 10 lakh infant deaths per year, with huge reductions
in the overall disease burden.
Achieving such declines requires looking at a range of
key interventions that address the major causal factors—
tetanus injections during pregnancy, professional attendance
with appropriate access to referrals during childbirth,
improvement in the mother’s nutrition to avoid low birth
weight infants, etc. Similarly, malnutrition makes a child
susceptible to diarrhoeal diseases and respiratory infections
which, when untreated, can be fatal. Beyond the phase of
infancy, immunization becomes critical in warding off
potentially fatal conditions. The enormous cross-state
variations in immunization rates and the low rates of
immunization in several States suggest great potential for
reducing the mortality from vaccine-preventable conditions.
Apart from these medical and nutritional interventions,
there are other non-health interventions that also need to
be considered in policy design, such as reducing discriminatory
practices towards the girl child, enhanced schooling
of females, better roads, access to clean drinking water,
electricity and other infrastructure, as these are known to
have a beneficial impact on the IMR, widening access to
timely care, etc.
Overall, the potential gains from these interventions can
be massive. According to NCMH estimates, a reduction in
childhood mortality may raise the life expectancy at birth
of an Indian by as much as 3.1 years, and India’s Gross
Domestic Product (GDP) from 4% to 12%.
Similarly, with the likelihood of 18% of all Indians dying
before the age of 40 years (Jha and Nguyen 2001; Deolalikar,
forthcoming), about 8.5% of a cohort born in any given year
can expect to die between the ages of 5 and 40, in contrast
to the UK’s 1.5% (Jha and Nguyen 2001; World Bank 2004).
Several factors contribute to this difference. First, the
MMR in India is substantial. The mortality from HIV/
AIDS and associated infections such as TB, injuries, especially
road traffic accidents, and cancers is high and expected to
increase given risky heterosexual activity and the factors
that promote it—mobile populations, rising incomes and
income inequality, the low status of women and the presence
of high-risk vulnerable groups; current tobacco consumption
patterns among young adults; and increase in traffic and
lax enforcement of traffic regulations, etc.
To address the above conditions a combination of
interventions will be needed. Most can be effectively
countered by implementing a range of low-cost solutions;
for example, peer education, access to condoms, a climate
of destigmatization, use of antiretroviral drugs to reduce
the risk of mother-to-child transmission of HIV infection,
and treatment of sexually transmitted diseases (STDs)
appear to be extremely cost-effective options for tackling
HIV/AIDS. Vaccination against TB infection, effective
identification of smear-positive cases of TB before they can
infect others, and strict implementation of an appropriately
designed Directly Observed Treatment, Short-course (DOTS)
are effective methods for reducing the mortality rate from
smear-positive TB as well as the rates of transmission.
NCMH Background Papers—Burden of Disease in India
Disease burden in India: Estimations and causal analysis
According to the Commission on Macroeconomics and
Health (CMH) estimates, properly administered DOTS can
reduce case-fatality rates resulting from smear-positive TB
from 60%–70% to 5%. Rough calculations undertaken
by the NCMH suggest that a reduction in mortality due to
TB in India by one-half would raise the life expectancy of
an Indian by 0.12 years and India’s overall GDP by as
much as 0.5%.
Huge gains in mortality reduction among young adults
are likely by reducing smoking and tobacco use. Analysis
of the National Sample Survey data by the NCMH showed
that nearly 40% of Indian males smoke. Tobacco consumption
and smoking have been linked to lung and oral cancers,
and TB. Shah (unpublished) suggests that India’s current
patterns of tobacco use and smoking is likely to sharply
increase the incidence of oral cancer in the future. Costeffective
interventions to address smoking include: ending
advertising for cigarettes, beedis and other tobacco products,
enhanced taxes on cigarette sales and production, and
dissemination of health messages. The NCMH estimates
that a 50% reduction in mortality rates due to CVD can
raise the life expectancy at birth of an average Indian by
1.3 years and India’s GDP by 2%–5%.
The issue of road traffic accidents is gaining attention
as these are major killers of young, and often poor, adults
in India. Many of the measures to address accidents and
their impact lie outside the realm of the health sector, and
may often have to do with urban planning, road designs
(including pedestrian and bicyclist access), vehicle quality
and design features, driving skills, lack of helmets and
control of speed. These require improved regulatory design
as well as better enforcement of the law against traffic rule
violators. Besides, addressing alcohol consumption, which
may impair response time and the overall ability to drive
safely, needs far greater attention than has been the case so
far. Estimates from Bangalore, Haryana and Punjab suggest
that nearly 40% of truck-related accidents and 60% of
those involving cars are alcohol-related. Interventions to
address alcohol consumption may include tax increases
since price elasticity of demand for alcohol in India appears
to be high, accompanied by health messages. Another factor
that ought to worry policy-makers is the huge burden of
disease on account of mental health disorders. These require
a range of skills that India does not have in adequate number
as well as access to drugs, which are expensive.
The older age groups are typically more vulnerable to
chronic diseases and are also at high risk for CVD. As
obesity, hypertension and diabetes are linked to the onset
of CVD, health education programmes that promote
exercise and weight reduction; screening for hypertension
as another pathway to both influence exercise and dietary
behaviour; early treatment; reduced smoking; selective
taxation of foods, etc. need to be accorded high priority.
The actual treatment of cancers and procedures for CVD
(angioplasties and coronary artery bypass graft are considerably
less likely to be cost-effective while their adverse
financial implications to affected households could be
extremely large.
An important element of the intervention strategy must
be to identify the mechanism through which such services
are to be delivered. Annexure B presents a schematic
framework on how some of the preventive and curative
interventions are to be provided at different levels of care—
at the community level, subcentre level, primary health
centre, community health centre, and ultimately, at the
district hospital. The framework of Annexure B is intended
to be suggestive rather than prescriptive in that it does not
imply that the concerned services have to be provided only
by the public sector, or that they ought to be free for
everyone.
A key lesson that has emerged from this effort is the
acute paucity of good data and the absence of communitybased
studies, which have made it impossible to come up
with any credible estimates of the disease burden in India.
This has, in no small measure, been further worsened by
the wide diversity and disparities that characterize this
country, making it difficult to extrapolate the data of small,
localized studies to the entire country. India should urgently
undertake operational research, establish good surveillance
systems and develop validated data banks. The data gaps
need to be bridged, high priority accorded to operational
research and adequate resources allocated.
References
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Raising the sights: Better health systems for India’s poor.
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