Efforts to Prevent & Control NCDs in India

Dr. Damodar Bachani

Director Professor in Community Medicine, LHMC &

Dy. Commissioner (NCD), Ministry of Health & FW

Proportional Mortality in India (% of all deaths, all ages, both sexes)

24

11

6 2

10 10

37

Cancer

CDs, maternal, Perinatal & nutritional conditions

26

13

7 2 12

12

28

Cancer Diabetes

Injuries

CDs, maternal, Perinatal & nutritional conditions

Other NCDs

CVD CVD

COPD COPD

Diabetes Injuries Other NCDs

Source: WHO NCD County Profiles

2011 2014

Burden of NCD risk factors in India (2008)

Risk factor Prevalence

Proportion of insufficiently active population (15+ age group ) 14%

Per capita alcohol consumption in liters of pure alcohol (2010) 4.3

Proportion of population (above the age of 25 years) with raised blood pressure (140/90 mm Hg)

33%

Proportion of population (above the age of 20 years) who were overweight

11%

Proportion of population (above the age of 25 years) with raised blood glucose

10%

Proportion of population (above the age of 25 years, in both sexes) with raised total cholesterol

27%

http://www.who.int/nmh/publications/ncd_report_full_en.pdf

Risk factors based on DALY contribution in India

Diarrhea / LRI / Other Infectious

Cardio & Circulatory

Chronic Respiratory

TOBACCO USE IN INDIA

National Tobacco Control Programme, MoHFW

Prevalence of tobacco use (%) (GATS 2010)

274.9 million use tobacco in some form or other

163.7 million use smokeless forms of tobacco.

68.9 million smoke tobacco.

Type Males Females

Tobacco users 47.9 20.3

Smokers 24.3 2.9

Smokeless 32.9 18.4

Programs addressing NCDs

National Programme for Prevention & Control of Cancer,

Diabetes, CVD and Stroke (NPCDCS)

National Programme for Control of Blindness (NPCB)

National Mental Health Programme (NMHP)

National Programme for Health Care Elderly (NPHCE)

National Programme for Prevention & Control of Deafness (NPPCD)

National Tobacco Control Programme (NTCP)

National Oral Health Programme (NOHP)

Programme for Palliative Care

Schemes for Trauma Care and Burns

1. Health Promotion for healthy life styles that preclude NCDs and their risk factors

2. Specific prevention to reduce exposure to risk factors

3. Early Diagnosis through periodic/ opportunistic screening of population and better diagnostic facilities

4. Infrastructure Development and facilities required for management of NCDs

5. Human Resources and their capacity building for prevention and treatment of NCDs

Strategies

6. Establish Emergency Medical Services with rapid referral systems to reduce disability and mortality due to NCDs

7. Treatment and care of persons with NCDs including rehabilitation and palliative care

8. Health Legislation and population and evidence based interventions wherever applicable through multi-sectoral approach for prevention of NCDs

9. Building evidence for action through surveillance, monitoring and research.

Strategies

Village Level Activities

• Involvement of ASHAs / SHG

• Role of Village Health Nutrition Sanitation Committee

• Campaign to identify NCD cases

• Health Promotional Activities (Link with Swachh Bharat- e.g. Smoke Free villages, No-tobacco use)

NCD Services at Sub- Centre

Manpower available

ANM(1) , Male Health worker(1)

Services

• Screening of persons above 30 yrs. & Pregnant women by Health Workers for :

NCD risk factors (dietary habits, physical inactivity, alcohol abuse and tobacco use)

Random blood sugar (Glucometers)

BMI, Blood Pressure

• Health Promotion, Early warning signals of cancer

• Referral

10

NCD Services at PHCs

Manpower available

Medical Officers, Nurses, Health Supervisors,

Laboratory Technician, Health Educator etc.

Services

Opportunistic Screening for common NCDs

Strengthening of laboratory services

Health Promotion

Referral

11

NCD Services at CHCs

Infrastructure available

First referral unit for NCDs

Four Specialists; Physician, Surgeon,

Gynecologist & Paediatrician

OPD & Inpatient Facility (30 beds)

Common lab. Investigations

NCD clinic: 1 Doctor, 2 Nurses, 1Counselor, 1 Data

Entry Operator

12

NCD Services at CHCs

Early detection of common NCDs (Diabetes,

CVDs & Stroke) and appropriate treatment

Investigations : blood sugar, ECG, Total

Cholesterol, Serum creatinine, Blood Urea,

Urine albumin, etc.

Referral of complicated cases

Home based care of bedridden cases

Health Promotion

Screening for oral, cervical and breast Cancer

& palliative care

Data recording and reporting

13

District Hospital

NCD clinic :to provide emergency care and

management of Diabetes, CVDs and Stroke;

Manpower : 1 Doctor, 2 Nurses, 1 Physiotherapist, 2

Counselor, 1 Care Coordinator, 1 Data Entry Operator

Cardiac care unit (CCU): with 6-8 beds & equipped

with ventilator and other necessary CCU equipments

Dialysis – Optional

Cancer care : Day Care facility for chemotherapy & palliative care

Laboratory diagnostic facilities: such as lipid

profiles, ECG, ECHO, CT Scan etc.

14

15

Cardiac Care Unit in Kerala District Cancer Facility

Cardiac Care Unit, Leh

Screening of Cancer

Site Level Method

Cervix District Hospital Visual Inspection

using Dil. Acetic Acid

Breast CHC Breast Examination

Oral CHC Visual inspection

16

Medicines & Technology

• Standard list of equipment, medicines, diagnostic kits and other consumables as per Indian Public Health Standards (2012)

• Most of the items are procured by States as per standard procurement guidelines

• Poor persons with BPL cards get free services

• Procurement of generic medicines encouraged

• Many States have computerized inventory management system

District Hospital NCD Clinic, Geriatric Clinic, Cardiac Care Unit,

Cancer Care Facility etc. [Health Promotion; Early diagnosis & Management; Home Based Care;

Day Care Facility]

Community Health Center NCD Clinic, Geriatric Clinic

[Health Promotion, Early diagnosis & Management; Laboratory Investigations, Home Based Care, Referral]

Sub Center Screening Services

[Health Promotion; Opportunistic Screening; Referral]

Tertiary level Institute Medical Colleges, Tertiary Cancer Centres, Regional

geriatric Centres, Centres of Excellence

[Tertiary care, Training, Research]

Referral

NCD Services in Health System

Convergence with other Health Programs

Reproductive & Child Health Program:

• Screening for Gestational Diabetes

• Screening for Cervical & Breast cancer

• Hepatitis B vaccination

• Promoting breast feeding

National Adolescent Health Program & School Health Program

• Care of Diabetes (Type-I & II)

• Risk Factor screening during bi-annual check up

• Health promotion

• HPV Vaccination (TBC)

Convergence with other Health Programs

• Revised National TB Control Program (COPD & Diabetes)

• National Program for Control of Blindness (Screening for Diabetic Retinopathy)

• National Program for Health care of the Elderly

• National Mental Health Program (Alcohol Control)

• National AIDS Control Program (HIV-TB & HIV-HPV infection)

New Initiatives under consideration • Chronic Obstructive Pulmonary Diseases (COPD)

COPD is 2nd leading cause of death in India (13%) next only to Cardiovascular Diseases (26%). Air Pollution, Smoking and dusty occupations are the leading risk factors. COPD is likely to be included under NPCDCS

• Chronic Kidney Disease (CKD): Main causes of CKD are Diabetes, Hypertension and Chronic Infections of kidneys. CKD is also one of the causes of deaths among diabetics. Early identification of CKD and its timely management would be required to save lives. Late stages would require Dialysis and end-stage kidney disease would require kidney transplantation.

• Prevention of mortality & disability in Stroke: Stroke is one of complications of Hypertension. Early diagnosis and treatment can save lives and prevent disability. Training of healthcare personnel of and provision of medicines (Actilyse) during the golden hour can save lives

New Initiatives…. • Insulin for Treatment of Type-1 & Insulin Dependent Type-2:

There are more than 97,000 children with type-1 diabetes in India. It is proposed to provide Insulin to T1-DM children/adolescents and poor adults who are Insulin-dependent diabetics.

• Chemotherapy to Cancer Patients: Poor patients put on chemotherapy face financial hardship as these drugs are very costly. Provision of free/subsidized chemotherapy drugs will reduce economic burden

• Management of Haemophilia & Thalassemia: These are rare genetic blood disorders. Administration of Factor VIII or IX for Haemophilics Iron Chelating agents and repeated blood transfusion are required to Thalassemia Major

• Rheumatic Heart Disease: RHD pilot intervention in three selected districts (Gaya in Bihar, Hoshangabad in Madhya Pradesh and Firozabad in Uttar Pradesh),

Initiatives for Multi-sectoral Approach

to Prevent & Control NCDs

National NCD Summit, New Delhi: 23-24 August 2011

• Jointly organized by Ministry of Health & FW & WHO-India even before HLM on NCDs held in New York in September, 2011

• Nearly 300 delegates in various disciplines participated

• New Delhi Call for Action released at the conclusion of the summit

• 1.12 Acknowledge that addressing the problem requires a multi-sectoral response and vital role to be played by multiple partners and stakeholders including the Government, civil society, academia, industry and the private sector (excluding tobacco interests) and other stakeholders in the prevention and control of NCDs.

• 2.13 Facilitating active involvement of a wide range of government Ministries and Departments (such as Agriculture, Human Resource Development, Women and Child Development, Labour, Rural Development, Panchayati Raj, Social Justice & Empowerment, Communication & Information Technology, Industry, Transport, Housing and Urban Development, Finance, Information & Broadcasting, Law, Home Affairs, Food Processing Industries, Pharmaceuticals, Environment & Forests, AYUSH, Youth Affairs & Sports), NGOs, academia, civil society and the population as a whole;

Preparation of National Action Plan & Monitoring Framework for NCDs

• New Delhi (Feb 2013): Consultation with major stakeholders to review NCD surveillance in India

• Shimla (June 2013): Meeting of the Advisory Group constituted to develop Monitoring Framework for Prevention and Control of NCDs

• Government approved National Action Plan and Monitoring Framework for NCDs; India was the first country to do so.

• Three regional workshops held with the States and regional stakeholders at Guwahati, Bangalore and Delhi in Nov.-Dec 2013 to have consensus on Action Plan & MF and suggest strategies to achieve targets

National Monitoring Framework: Long Term Targets

Indicator 2020 2025

Relative reduction in premature mortality from NCDs

10% 25%

Obesity & Diabetes Prevalence: Halt the rise

Relative reduction in prevalence of insufficient physical activity

5% 10%

Relative reduction in the prevalence of raised blood pressure

10% 25%

Relative reduction in mean intake of salt/ sodium intake

20% 30%

Long Term Targets Indicator 2020 2025

Relative reduction in alcohol use 5% 10%

Relative reduction in prevalence of current tobacco use

15% 30%

Eligible people receive drug therapy and counselling to prevent heart attacks and strokes

30% 50%

Availability of essential NCD medicines & basic technologies to treat major NCDs public/private facilities

60% 80%

Relative reduction in household use of solid fuel (indoor pollution)

25% 50%

National Steering Committee on NCD Surveillance & Monitoring

Constituted on 25th Sept 2013 with members from Ministry of Health & FW, ICMR, Registrar General of India, subject experts and WHO Terms of Reference: • Measures of strengthen vital registration systems to increase coverage of

registration of deaths including medical causes of death;

• Framework for population based NCD Risk factors surveys;

• Framework for school based integrated risk factor Health Survey and convergence with school health programme and ARSH;

• Health facility survey (infrastructure, facilities, HR) for NCDs

• Development/strengthening of registries for Cancer & other NCDs;

• Development of Management Information System for routine programme related data and integration with HMIS;

• Policy analysis, identification of gaps & action points for multi-sectoral approach to prevention & control NCDs, risk factors and social determinants

• Identification of priority areas of operational and intervention research

First Meeting of the Steering Committee held on 28th Jan. 2014

Key Decisions

• Approval of National Monitoring Framework for Prevention and Control of NCDs

• Preparation of baseline Information on current level of Risk Factors for NCD (Action WHO & ICMR)

• Current Assessment of Burden of NCDs (Action-ICMR)

• WHO Framework and tools for population based NCD Risk factor survey & Need for Country Specific Information to be prepared (Action ICMR)

• ICMR was identified as the coordinating body to undertake above tasks

National Consultation for Development of National Multi-sectoral Action Plan for Prevention & Control of

NCDs

• Organized jointly by Ministry of Health & FW & WHO-India on 22-23 May 2014, New Delhi

• Delegates included officers from various sectors, academia, NGOs and International agencies

• Deliberations were held on four themes

Multi-sectoral approach

Health systems strengthening

Health promotion and advocacy

Monitoring and evaluation

Inter-ministerial Committee (IMC) to review and develop a comprehensive policy on tobacco

and tobacco related issues

• Government of India has recently (24 Nov. 2014) constituted IMC with Cabinet Secretary as Chair, Secretary (Health & FW) as Convener and Secretaries, M/o Home Affairs, Commerce, I&B, Agriculture, Revenue, Labour, Social Justice, WCB, School Education, Industrial Policy and Consumer Affairs as members

• First meeting held on 10th Dec. 2014

Steering Committee on Health Related Issues on Air Pollution

• Constituted on 6th January 2014

• Members include officers from M/o Health, New & Renewable Energy, Environment & Forests, Women & Child Development, Road Transport & Highways, Urban development, Central Pollution Control Board, IIT, PHFI, Centre for Science & Environment, Subject Experts & NGOs

• Two sub-groups are working on Ambient Air Pollution and Household Air Pollution

• Groups will examine extent and sources of air pollution, measures to reduce pollution and framework to monitor it

• Report submitted in August, 2015

Technical Resource Group on Alcohol Control • Constituted on 6th November, 2013 with Joint Secretary from Ministry of Health & FW

and Ministry of Social Justice & Empowerment are Co-chairs

• Members include representative of Youth Affairs and Sports, NIMHANS, AIIMS, ICMR, PHFI and NGOs

Terms of reference:

• Review existing policies & strategies for limiting production, supply & use of alcohol

• Collate evidence on harms of alcohol consumption for advocacy and policy decisions

• Identify strategies and interventions for reduction in public consumption of alcohol

• Review existing services available for drug and alcohol de-addiction

• Identify training needs of health care providers for inclusion in integrated training

• Identify areas for multi-sectoral approach to prevent and limit use of alcohol

• Develop schemes for involvement of NGOs and Civil Society org. in alcohol control

• Advise on advocacy and communication for public awareness

• Evolve framework for development of Surveillance systems

• Identify priority research areas relating to alcohol use, effectiveness of preventive strategies and outcomes of de-addiction services

Joint Core Group on Trauma • Constituted on 5th September, 2013

• Joint Secretary from Ministry of Health & FW and Ministry of Road Transport & Highways are Co-chairs

• Members include representative of National Highways Authority of India & AIIMS

• Terms of Reference

To identify strategies and develop Standard Operating Protocols for Road Safety, prevention and effective care of victims of Road Accidents

Sharing of information relating to Road Accidents for identification of suitable sites for developing Trauma Centres

Develop plans for capacity building of human resources engaged in various activities under the schemes

Coordinate in developing surveillance system of Road Accidents

• This group has brought in coordination in road safety measures, ambulance services and development of trauma care facilities on national and state highways

Issues & Challenges

• Full integration of vertical programs in Health System with effective linkages and referral system

• Involvement of Voluntary Organizations and Private Health Sector

• Multi-sectoral Approach for population based interventions: Economic, legal and environmental policies for healthy lifestyles

• Allocation of adequate resources for NCDs

Cancer

Chronic Lung Disease

Cardiovascular Diseases

Diabetes

OVERWEIGHT

SMOKING

ALCOHOL

UNHEALTHY DIET

PHYSICAL INACTIVITY

AIR POLLUTION

Hit the Route & Trunk, branches will fall automatically

NCD Prevention and Control

Social Determinants