Informing NCD control efforts in India on the eve of Ayushman Bharat
Authors: Balram Bhargava, Vinod K Paul
Journal: The Lancet (2018)

The Government of India recently launched the ambitious National Health Protection Mission, also referred to as Ayushman Bharat (which means "bless India with long healthy life"), Pradhan Mantri Jan Arogya Yojana, or Modicare. This scheme has two main pillars: strengthening of universal comprehensive primary health care and a health insurance scheme to cover 500 million people in need to reduce catastrophic out-of-pocket health spending.1National Health PortalCentre for Health InformaticsMinistry of Health and Family WelfareGovernment of IndiaAyushman Bharat Yojana.https://www.nhp.gov.in/ayushman-bharat-yojana_pgDate accessed: August 10, 2018Google Scholar, 2Press Information BureauGovernment of IndiaNational consultation on Ayushman Bharat: operationalizing health and wellness centres to deliver comprehensive primary health care.http://pib.nic.in/newsite/PrintRelease.aspx?relid=179095Date: May 3, 2018Date accessed: August 10, 2018Google Scholar The 1·3 billion population of India has vast socioeconomic and health diversity across the country. In November, 2017, the India State-Level Disease Burden Initiative3India State-Level Disease Burden Initiative CollaboratorsNations within a nation: variations in epidemiological transition across the states of India, 1990–2016 in the Global Burden of Disease Study.Lancet. 2017; 390: 2437-2460Summary Full Text Full Text PDF PubMed Scopus (399) Google Scholar, 4ICMRPHFIIHMEIndia: health of the nation's states—the India State-Level Disease Burden Initiative. Indian Council of Medical Research, Public Health Foundation of India, Institute for Health Metrics and Evaluation, New Delhi2017Google Scholar reported the first assessment of trends in all of the major diseases and risk factors in every state of India from 1990 to 2016 using the single framework of the Global Burden of Disease study, which generated considerable policy interest.5Ministry of FinanceGovernment of IndiaEconomic Survey 2017–2018.http://mofapp.nic.in:8080/economicsurvey/Date accessed: August 10, 2018Google Scholar Five Articles published today by this Initiative report further detailed analyses of several major non-communicable diseases (NCDs) and suicide across the states of India over a quarter of a century.6India State-Level Disease Burden Initiative CVD CollaboratorsThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30407-8Google Scholar, 7India State-Level Disease Burden Initiative Diabetes CollaboratorsThe increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30387-5Google Scholar, 8India State-Level Disease Burden Initiative CRD CollaboratorsThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30409-1Google Scholar, 9India State-Level Disease Burden Initiative Cancer CollaboratorsThe burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Oncol. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S1470-2045(18)30447-9Google Scholar, 10The India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2468-2667(18)30138-5Google Scholar This new evidence can be a useful input for the state-specific planning of Ayushman Bharat, as disability-adjusted life-years (DALYs; a composite metric of premature mortality and morbidity recommended by the Health Policy of India for disease burden monitoring11Ministry of Health and Family WelfareGovernment of IndiaNational health policy of India.https://mohfw.gov.in/documents/policyDate: 2017Date accessed: August 10, 2018Google Scholar) from NCDs and injuries have together exceeded those from communicable diseases in every state of India, contributing 57–86% of the total DALYs among the states in 2016.4ICMRPHFIIHMEIndia: health of the nation's states—the India State-Level Disease Burden Initiative. Indian Council of Medical Research, Public Health Foundation of India, Institute for Health Metrics and Evaluation, New Delhi2017Google Scholar The Government of India is focused on the need to address the high and increasing burden of NCDs and injuries in the country. Briefly, the integrated National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke established NCD units in each state last year to increase the momentum for the prevention and management of major NCDs at the district level, including screening for high blood pressure and blood glucose and for oral, breast, and cervical cancers.12Directorate General of Health ServicesMinistry of Health and Family WelfareGovernment of IndiaNational Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke.http://dghs.gov.in/content/1363_3_NationalProgrammePreventionControl.aspxDate accessed: August 10, 2018Google Scholar The National Tobacco Control Programme is facilitating reduction of the prevalence of smoking in India.6India State-Level Disease Burden Initiative CVD CollaboratorsThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30407-8Google Scholar The Food Safety and Standards Authority of India last year proposed a tax and advertisement ban on unhealthy foods.13Food Safety and Standards Authority of IndiaGovernment of IndiaReport of the expert group on consumption of fat, sugar & salt and its health effects on Indian population. Food Safety and Standards Authority of India, New Delhi2017Google Scholar The availability of non-polluting cooking fuels for low-income households has increased under the nationwide Pradhan Mantri Ujjwala Yojana scheme.14Ministry of Petroleum and Natural GasGovernment of IndiaPradhan Mantri Ujjwala Yojana: State-wise PMUY connections released.http://www.pmujjwalayojana.com/released-connections.htmlDate accessed: August 10, 2018Google Scholar India also has initiatives related to suicide, including the National Mental Health Policy and the Protection of Women from Domestic Violence Act.15Ministry of Health & Family WelfareGovernment of IndiaNational Mental Health Policy of India—New Pathways New Hope.https://www.nhp.gov.in/sites/default/files/pdf/national%20mental%20health%20policy%20of%20india%202014.pdfDate: 2014Date accessed: August 10, 2018Google Scholar, 16Government of IndiaThe Protection of Women from Domestic Violence Act.http://ncw.nic.in/acts/TheProtectionofWomenfromDomesticViolenceAct2005.pdfDate: 2005Date accessed: August 10, 2018Google Scholar The government has planned the establishment of 150 14;000 health and wellness centres across India to provide comprehensive primary health-care services that would help to deal with NCDs and injuries along with communicable diseases, as part of Ayushman Bharat.2Press Information BureauGovernment of IndiaNational consultation on Ayushman Bharat: operationalizing health and wellness centres to deliver comprehensive primary health care.http://pib.nic.in/newsite/PrintRelease.aspx?relid=179095Date: May 3, 2018Date accessed: August 10, 2018Google Scholar Deliberations on operationalising this effort, led by the Government of India and involving the key decision makers from all states and a range of other stakeholders, point to the acute interest of the government in strengthening prevention and management of the full range of diseases and risk factors in each state.2Press Information BureauGovernment of IndiaNational consultation on Ayushman Bharat: operationalizing health and wellness centres to deliver comprehensive primary health care.http://pib.nic.in/newsite/PrintRelease.aspx?relid=179095Date: May 3, 2018Date accessed: August 10, 2018Google Scholar The Government of India is keen to use the latest available evidence to maximise the impact of Ayushman Bharat. In relation to this opportunity, we summarise the key policy implications of the findings of the India State-Level Disease Burden Initiative.6India State-Level Disease Burden Initiative CVD CollaboratorsThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30407-8Google Scholar, 7India State-Level Disease Burden Initiative Diabetes CollaboratorsThe increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30387-5Google Scholar, 8India State-Level Disease Burden Initiative CRD CollaboratorsThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30409-1Google Scholar, 9India State-Level Disease Burden Initiative Cancer CollaboratorsThe burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Oncol. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S1470-2045(18)30447-9Google Scholar, 10The India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2468-2667(18)30138-5Google Scholar One striking finding is that the age-standardised increase in the prevalence of ischaemic heart disease and diabetes, as well as their DALYs, has generally been highest in the less developed states of India, where the burden of another major NCD, chronic obstructive pulmonary disease (COPD), and communicable diseases is already high.6India State-Level Disease Burden Initiative CVD CollaboratorsThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30407-8Google Scholar, 7India State-Level Disease Burden Initiative Diabetes CollaboratorsThe increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30387-5Google Scholar, 8India State-Level Disease Burden Initiative CRD CollaboratorsThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30409-1Google Scholar Among the major risk factors for ischaemic heart disease, stroke, and diabetes, the prevalence of high blood pressure, high cholesterol, high fasting plasma glucose, and overweight has increased in all parts of India.6India State-Level Disease Burden Initiative CVD CollaboratorsThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30407-8Google Scholar, 7India State-Level Disease Burden Initiative Diabetes CollaboratorsThe increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30387-5Google Scholar The high exposure to ambient and household air pollution in the less developed northern states is contributing to the high burden of COPD in these states, in which the case-fatality rate of COPD is twice as high as in the more developed states.8India State-Level Disease Burden Initiative CRD CollaboratorsThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30409-1Google Scholar Additionally, ageing of the population is adding to the increasing burden of NCDs. These findings emphasise the need for the prevention and management of major NCDs to receive as much policy attention in these states as the reduction of the still high burden of communicable and childhood diseases. India has focused on the early detection of breast, oral, and cervical cancers, but the findings on cancer suggest that the large numbers of DALYs caused by stomach, lung, pharynx, and some other cancers also need to be addressed.9India State-Level Disease Burden Initiative Cancer CollaboratorsThe burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Oncol. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S1470-2045(18)30447-9Google Scholar The wide variations among the states in the patterns of different cancers over time point to the need for better understanding of the drivers of these trends to enable more informed intervention planning. The Article on suicide10The India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2468-2667(18)30138-5Google Scholar highlights that this type of injury is the leading cause of death in young adults in India aged 15–39 years, that the suicide death rate among elderly people has increased over the past 25 years, and that India now contributes 37% of the total deaths by suicide among women worldwide. The suicide death rate between the states of India varies by ten times for women and six times for men, but the factors responsible for these variations are not well understood, pointing to a knowledge gap that needs to be addressed. India's policy has focused on health improvements in the less developed Empowered Action Group states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, and Uttarakhand, as well as Assam. The findings in these Articles, that the major NCDs or injuries do not necessarily follow similar trends among the less developed states or among the more developed states (figure),6India State-Level Disease Burden Initiative CVD CollaboratorsThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30407-8Google Scholar, 7India State-Level Disease Burden Initiative Diabetes CollaboratorsThe increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30387-5Google Scholar, 8India State-Level Disease Burden Initiative CRD CollaboratorsThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30409-1Google Scholar, 9India State-Level Disease Burden Initiative Cancer CollaboratorsThe burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Oncol. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S1470-2045(18)30447-9Google Scholar, 10The India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2468-2667(18)30138-5Google Scholar, 17Indian Council of Medical ResearchPublic Health Foundation of IndiaInstitute for Health Metrics and EvaluationGBD India compare data visualization.http://vizhub.healthdata.org/gbd-compare/indiaDate accessed: August 1, 2018Google Scholar highlight the need to plan for the specific situation in each state. India needs to invest in suitable surveillance systems to monitor the changing trends in NCDs and injuries, and their related risk factors, across the country. India's cancer registry programme is well regarded, but even this does not cover some large, less developed states and the surveillance of many NCDs and injuries needs strengthening. Yet another data gap is that only a small portion of the deaths in India have their cause medically certified, indicating that the cause of death reporting system in India has to be improved to enable more robust tracking of disease burden. While there are limitations to the findings reported in these Articles because of data gaps, the detailed composite analyses reported using all accessible data over a quarter of a century are useful to guide the calibration of policy interventions under Ayushman Bharat in different parts of the country with the aim of reducing health disparities between the states of India. We are employees of the Government of India. Lalit Dandona, Director of the India State-Level Disease Burden Initiative, helped to coordinate the writing of this Comment. Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016India's proportional contribution to global suicide deaths is high and increasing. SDR in India is higher than expected for its Socio-Demographic Index level, especially for women, with substantial variations in the magnitude and men-to-women ratio between the states. India must develop a suicide prevention strategy that takes into account these variations in order to address this major public health problem. Full-Text PDF Open AccessThe burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016The substantial heterogeneity in the state-level incidence rate and health loss trends of the different types of cancer in India over this 26-year period should be taken into account to strengthen infrastructure and human resources for cancer prevention and control at both the national and state levels. These efforts should focus on the ten cancers contributing the highest DALYs in India, including cancers of the stomach, lung, pharynx other than nasopharynx, colon and rectum, leukaemia, oesophageal, and brain and nervous system, in addition to breast, lip and oral cavity, and cervical cancer, which are currently the focus of screening and early detection programmes. Full-Text PDF Open AccessCancer trends and disparities in India: data needs for providing equitable cancer careIndia, with a population close to 1·3 billion, and growing, is epidemiologically interesting and challenging for health-care planners. Regarding cancer burden, the population demographics, health policies, health-data recording, access to health care, and affordability have all improved substantially during the period between 1990 and 2016, as reported by The India State-Level Disease Burden Initiative Cancer Collaborators in their Global Burden of Disease paper in The Lancet Oncology.1 In addition to the heterogeneity in cancer incidence and outcomes between states, significant differences exist within each state, most prominently between urban and rural populations. Full-Text PDF Open AccessThe increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016The increase in health loss from diabetes since 1990 in India is the highest among major non-communicable diseases. With this increase observed in every state of the country, and the relative rate of increase highest in several less developed low ETL states, policy action that takes these state-level differences into account is needed urgently to control this potentially explosive public health situation. Full-Text PDF Open AccessOffline: The new politics of health in India"There is a full-blown crisis in India." So said Rahul Gandhi, President of the Indian National Congress Party, during a visit to the London School of Economics last month. He was talking about a "jobs crisis". But there is also a health crisis, as five papers published across three Lancet specialty journals—Lancet Oncology, Global Health, and Public Health—set out this week. Now is the right moment to be debating the future health of the world's largest democracy. In April, 2019, Indian voters will go to the polls in the most important general election since India achieved independence in 1947. Full-Text PDF Open AccessSuicide in India: a complex public health tragedy in need of a planSuicide is a major public health problem, with far-reaching socioeconomic, political, and emotional consequences. Southeast Asia accounts for roughly 40% of the estimated 800 000 annual suicide deaths globally,1 and is the frontline for delivering on the aspirational Sustainable Development Goal (SDG) of a one-third reduction in the suicide death rate (SDR) by 2030. Full-Text PDF Open AccessThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016The burden from the leading cardiovascular diseases in India—ischaemic heart disease and stroke—varies widely between the states. Their increasing prevalence and that of several major risk factors in every part of India, especially the highest increase in the prevalence of ischaemic heart disease in the less developed low ETL states, indicates the need for urgent policy and health system response appropriate for the situation in each state. Full-Text PDF Open AccessThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990–2016India has a disproportionately high burden of chronic respiratory diseases. The increasing contribution of these diseases to the overall disease burden across India and the high rate of health loss from them, especially in the less developed low ETL states, highlights the need for focused policy interventions to address this significant cause of disease burden in India. Full-Text PDF Open Access