Shoba John is the programme director of HealthBridge Foundation of Canada, based in India. She talks to Vibha Varshney on how the burden of non-communicable diseases (NCDs) can be reduced in India. The foundation is working with the government of India to implement effective interventions.
How big is the problem of non-communicable diseases in India?
Four major non-communicable diseases—cardio vascular diseases, cancers, diabetes and chronic respiratory diseases are responsible for 53 per cent of total deaths in India every year. WHO estimates that over 60 million Indians will die from these diseases by 2020. These diseases translate into a major drain on the country's productive workforce. NCDs affect the poor more – for example, tobacco-use, the only risk factor common to all the four major NCDs, shows a continual increase with decreasing wealth quintiles in the country.
How can we reduce the burden?
In addition to public health interventions, India needs to use its development programmes to reach hard-to-reach and high-risk groups. A case in point is the Integrated Child Development Scheme (ICDS) which covers 74.8 million children under six years of age and 18 million pregnant and lactating mothers. The programme can be engaged to promote healthy eating and physically active lifestyle among families. The ‘kisaan haats’ (farmer’s markets) under the National Rural Livelihood Mission can deliver fresh, locally-produced vegetables and fruits to communities and facilitate healthy eating. Similarly, Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), which ensures livelihood security in rural areas by providing 100 days of employment, could serve as a vehicle to deliver NCD interventions, ranging from prevention, to diagnosis and insurance support for treatment. For example, people who work under MGNREGA can be reached for screening and referrals through worksite interventions. The locality development component of the programme has the scope to build playgrounds, walking and cycling paths in rural areas, thus facilitating healthier lifestyles that help prevent NCDs.
What is the evidence that using development programmes for reducing NCD will work?
What we are saying is that there is a clear opportunity for integration and it needs to be tried. This is one way to cater to hard-to-reach and high-risk groups. By using these programmes, we can also leverage the mandates and resources of ministries beyond health. We have already seen contributions by multiple agencies working to improve health. In case of HIV/AIDS control, initial interventions were led by Union Ministry of Health and Family Welfare. Now, the patients' needs are being addressed by ministries as diverse as Indian Railways, which runs the Red Ribbon Express that offers testing and counselling services and subsidised travel to access treatment. Similarly, in case of tobacco control, ministry of agriculture is exploring alternative crops to tobacco, ministry of finance has used options such as taxation to reduce tobacco use, while ministry of information and broadcasting is regulating advertisements, even as ministry of health lends leadership and coordination.
But HIV/AIDS and tobacco control seem to be successful due to policy interventions, and your advice on NCDs does not involve any policy change. Why do you say these will work in a similar fashion?
For effective control, both policy and programme interventions are needed. Policy interventions in case of NCDs are in a nascent stage in the country—we do not have comprehensive policies regulating sweetened sodas, junk food or even alcohol. Even in the case of tobacco, we are far from meeting critical stipulations set down by the Framework Convention on Tobacco Control. Our goals are clear—we need policies for population-wide prevention and control of NCDs. Even as we advocate their development, we feel there is scope to explore existing programme interventions. This will generate the evidence that could then be translated into policy. For instance, early pilot interventions that explore the synergies between ICDS and NCD programmes could inform eventual policy decisions regarding the optimal levels of integration between the programmes.
You suggest a multi-sectoral strategy on reducing the impact of NCDs. In India, other problems such as those on reducing malnutrition have involved many ministries. But these ministries fail to work together. Why would your suggestions work in case of NCDs?
Two commonly observed challenges in multi-sectoral work across government agencies include ambiguity about who is responsible to make it happen and whose funds would be used for the same. Inter-ministerial action on NCDs, therefore, calls for two specific requirements. First of all, the multi-sectoral action needs to be considered right from the time of programme planning, and not as an ‘after thought’. Responsibility for inter-sectoral action needs to be fixed at all levels of programme delivery across ministries and specific deliverables are to be identified for each agency.
Secondly, the multi-sectoral component of the programme needs to have its own budget lines to undertake specific measures. There is thus scope to leverage a development programme like MGNREGA to develop cycling paths or playgrounds. Ministries of finance and commerce have a central role in propelling price and trade policies for cars, cycles and sports equipment, which would have direct bearing on physical activity.
Action Plan: WHO global action plan for the prevention and control of NCDs 2013-2020
Report: Chronic emergency: why NCDs matter
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