Navigating the road to 2030 development goals
doi:10.1038/nindia.2018.160 Published online 5 December 2018By 2030, the United Nations’ deadline for accomplishing the Sustainable Development Goals (SDGs), India will have the world’s largest population, having attained that status by 2024. The probability of SDGs being reached, therefore, relies substantially on India overcoming its health challenges. If the anticipated demographic dividend of accelerated economic growth, propelled by a productive population is to be realised, the country must improve the health status of its large, and mostly young population.
India entered the SDG era lagging in the health targets set by the Millennium Development Goals (MDGs). Even as it rededicates itself to improvements in maternal and child health, and control of major infectious diseases (TB, HIV- AIDS, malaria), it must also deal with the mounting menace of non-communicable diseases (NCDs), mental health problems, pollutants, and addictions, all now recognised major public health threats. There are also further conditions to the global health agenda, with the SDGs also calling for Universal Health Coverage (UHC) and improved access to reproductive health services. Given this broad agenda, where is India’s health as it sets out on the road to SDGs?
India is undergoing multiple transitions: developmental, demographic, nutritional, environmental, technological and cultural. The pace of these transitions varies across a vast geography and diverse population. Aggregate national indicators mask the large variations across states and the huge gaps that exist between population groups. Still, the rise of NCDs and reduction in the burden of infectious diseases is a consistent pattern across the country. Life expectancy is the second lowest in South Asia and maternal and child mortality rates are four to five times higher than in China and Sri Lanka.
Maternal mortality ratio (MMR) is now 130 per 100,000 live births, a vast improvement from 677 in 1980 and 556 in 1990. The launch of the National Rural Health Mission (NRHM) in 2005 helped achieve the decline, with a strong focus on maternal and child health. The success came through the induction of women community health mobilisers in villages, financial incentives to promote institutional deliveries and the increase of emergency transport services.
Quality of care at the institutional level remains a concern, but if that can be improved, India should be able to achieve the 2030 MMR target of 70, and the under-five mortality target of 25 (down from 43 presently). Neonatal mortality has remained a major concern, demanding improvements in both antenatal and institutional care of mother and baby. The National Family Health Survey of 2016 has revealed a high prevalence of undernutrition in children under five (38.4% stunted; 35.7% underweight; 21% wasted).
Tuberculosis (TB) prevalence and mortality have been reduced, but drug resistant TB is rising, with India expected to have 42% of the world's cases by 2020. HIV prevalence has been reduced, but cuts in programme funding increases risk of resurgence. Malaria continues to be a major challenge in states with large tribal populations and north eastern states. Other vector borne diseases like Chikungunya and dengue are now familiar threats in many parts of India. There are new concerns about the impact of climate change on health and nutrition.
NCDs are now the leading contributors to mortality (63%) and loss of Disability Adjusted Life Years (55%). Cardiovascular diseases, cancers, chronic obstructive diseases are claiming lives in productive years (56% of NCD deaths occur below 70 years; 40% below 65 years). Mental health disorders are a major contributor to morbidity.
Even as risk factors like high blood pressure and cholesterol and excessive weight are on the rise in both urban and rural populations, undernutrition and air pollution are the top two - risk factors of ill health in India. Tobacco consumption, another major risk factor, has declined over the past decade, but remains high with 25% of adults using, beedi and cigarettes most commonly. Air pollution takes its toll, both outdoors, and indoors, due to burning of solid biomass fuels for cooking. Tobacco and air pollution each account for more than a million deaths annually.
A pronounced predilection for diabetes contributes to high burdens of cardiovascular and renal disease, linked to many factors ranging from intra uterine and early childhood malnutrition to diets rich in refined carbohydrates and sedentary lifestyles. High levels of abdominal obesity and low muscle mass portray the physical picture of metabolic compromise.
While multiple public health challenges threaten individuals, under-resourced health systems are overwhelmed by mounting demands of prevention, diagnosis and treatment. Access to quality health care is limited in rural areas and urban slums.
With low levels of health expenditure overall (1.2% of GDP) and especially of public financing (25% of all health spending), there are high out-of-pocket costs (64%). Private health insurance has low penetration. While several government funded health insurance schemes have increased access of poor families to hospital care, they have failed to provide financial protection as measured by out of pocket expenditure, or healthcare related impoverishment. It has been estimated that 7% of the Indian population is pushed into poverty by health expenditure in any year.
Since 2005, policies to strengthen the health system and improve health outcomes have been tried. The National Health Mission (with rural and urban components), the government funded health financing schemes for the poor (Rashtriya Swasthya Bima Yojana, soon to be replaced by a larger funded National Health Protection Scheme) and a large number of disease control programmes are responding to existing and emerging public health challenges.
Trans-disciplinary research in several domains of health must invigorate the multi-sectoral and health system responses needed for protecting and promoting India’s health. Research must extend across and integrate several domains. Biomedical, epidemiological, clinical, health systems, health technologies, health policy and implementation must all be considered in tandem in order to improve knowledge and have it translated to useful products and services.
Health research must engage in answering questions that range from aetiology and mechanistic pathways to innovative technologies, cost-effective and affordable delivery systems for health interventions, as well as the social and environmental determinants of health.
Why do Indians have a proclivity for developing diabetes, especially when a third of those who do are thin? Given the ethnic, genetic, geographic, climatic and dietary and developmental diversity of India, there are many interesting scientific questions on gene-environmental interactions and modifiable epigenetic effects, as well as the microbiome, that are best answered in the Indian population.
Similarly, the role of innovative, frugal and impactful technologies in enhancing the outreach, effectiveness and equity dimensions of health services may be studied in the Indian context, but will yield valuable knowledge which can be applied in many other countries. As India marches towards the SDG 2030 deadline, the world will be watching, to track her progress, and benefit from her experience and expertise.
[K. Srinath Reddy is President, Public Health Foundation of India. Views expressed in this article are personal.]