Open Forum

New Delhi, 2 February 2017

Disease Burden

INVESTMENT IN HEALTH  CRITICAL 

By Dr Oishee Mukherjee

There has been international pressure to increase investment in health as the burden of diseases has been increasing with the rise in population levels. More than communicable diseases, the rise is particularly noticeable among the non-communicable ones, which includes lifestyle diseases.  Obviously, the poorer sections have to bear the major share of this burden.     

The scale of the problem is significant as India accounts for a third of the world’s poorest 1.2 billion people and 21 per cent of the world’s disease burden. Our poor health is making us poorer still. The country faces triple health threat — infectious diseases, violence/ injuries and non-communicable diseases (NCDs), like cardiovascular diseases, cancers, chronic respiratory disease and diabetes. According to the Institute for Health Metrics and Evaluation (IHME), the burden from infectious diseases reduced between 1990 and 2010 but premature deaths and disability due to injuries and NCDs significantly increased.      

It has been estimated that India loses 6 per cent of its annual GDP to preventable illnesses and premature deaths. NCDs are responsible for 60 per cent of deaths in India, account for 40 per cent of hospital stays and 35 per cent of outpatient visits. Since public health expenditure in India is less than 1 per cent of GDP — among the lowest in the world — individuals and their families bear the brunt of the cost. The World Health Organization (WHO) says this pushes an estimated 2.2 per cent of Indians into poverty each year.

Among communicable diseases, mention may be made of tuberculosis which has not yet been controlled with India accounting for a fourth of all such cases. While officially India’s annual burden of TB cases stood at roughly 2.2 million a year, a recent study published in The Lancet infectious disease journal (on August 25, 2016) pegs the number at over 3.8 million in 2014. This excludes drug resistant TB cases. The study, jointly conducted by the Indian government, Imperial College of London and Bill & Melinda Gates Foundation, confirmed what has long been suspected – more Indian TB patients seek treatment in the private sector.       

In spite of all this, Government expenditure on health, at around 1.3 per cent of GDP, significantly lags behind budgetary allocations being made by peer countries, which is estimated to be around three to four per cent of GDP. Moreover, public health and infrastructure and staff availability are woefully short of actual demand. It is estimated that the country faces a shortfall of nearly 50 per cent in the supply of doctors with the doctor-to-patient ratio of 0.57 per 1000 being 53 per cent lower than the equivalent ratio of 1.2 per 1000 in the average Asian countries. The problem is most acute in the northern and eastern States.       

The fact cannot be denied that poverty and disease are tied closely together, with each factor aiding the other. Many diseases that primarily affect the poor serve to also deepen poverty and worsen conditions. Poverty also significantly reduces people’s capabilities making it more difficult to avoid poverty related diseases. The majority of diseases and related mortality in poor countries is due to preventable, treatable diseases for which medicines and treatment regimes are readily available.

Poverty is in many cases the single dominating factor in higher rates of prevalence of these diseases. Poor hygiene, ignorance in health-related education, non-availability of safe drinking water, inadequate nutrition and indoor pollution are factors exacerbated by poverty. While the spectre of the problem is quite serious in rural areas, the picture in slums and squatter settlements is no less better. But the cause in the latter case is due to acute pollution, specially in the metros and cities.      

Just the big three PRDs — TB, AIDS/HIV and malaria — account for 18 per cent of diseases in poor countries. The disease burden of treatable childhood diseases in high-mortality, poor countries is 5.2 per cent in terms of disability-adjusted life years but just 0.2 per cent in the case of advanced countries. In addition, infant mortality and maternal mortality are far more prevalent among the poor. For example, 98 per cent of the 11,600 daily maternal and neonatal deaths occur in developing countries.

The future outlook appears quite bleak. Poor diets (including high caloric diets), household air pollution and tobacco use are the top three risk factors for NCDs in India, according to the IHME. The toll of NCDs is expected to rise further with increased urbanisation, which is associated with lower levels of physical activity and increased consumption of commercially processed, energy-dense (nutrient deficient) foods that fuel obesity. According to the Harvard School of Public Health, NCDs and mental health conditions will cost India $4.58 trillion in economic losses by 2030.

Private treatment is obviously quite costly but the study has not stated clearly the break-up of patients availing public and private facilities. However, it is believed that India’s private sector was treating an enormous number of TB patients, appreciable higher than was previously recognised. This brings up the questions regarding public sector health facilities existing in rural areas for which patients go to private clinics or nursing homes even bearing the burden of higher costs, sometimes with great difficulty.

The need of the day is to give proper attention to health, specially in rural areas. While the target should be to set up one hospital in each sub-division, the immediate priority should be to activate the rural health centres and the existing hospitals with doctors, nurses and medicines. As is well-known, the poor and the economically weaker sections are the victims of diseases and do cannot afford private treatment, it is imperative that the health infrastructure is strengthened in the rural areas.     

Reducing preventable disease should be a high development priority, and now is the time to invest in a healthier, wealthier future for India. It is indeed surprising that low priority has been given to health over the years. There have been suggestions – specially by the World Economic Forum in its report ‘Leapfrogging in Emerging Economies’-- to develop a holistic understanding of challenges through strategies to ensure systems that are financially sustainable while delivering high quality, cost-effective care.  

Thus it needs to be reiterated that keeping in view the fact that India accounts for a third of the world’s poorest 1.2 billion people and over 21 per cent of the world’s disease burden, preventive action needs to be taken immediately so that our poor health should not make us poorer still. Though quite late in the day, a sustainable health care system needs to be evolved with access to a wide range of technological process and operating innovations. There is significant opportunity to invest in new solutions, given the limited costs incurred on existing health infrastructure and experimenting with entrenched techniques to ameliorate the sufferings of the poor and the impoverished. ---INFA

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