Prioritizing NCDs: A Key to Achieve Sustainable Development Goals
National Health Policy
Recognises and Addresses
NCDs Goals in SDGs:
Now We Need Implementation
How to Address the Issue of
Inadequate Financing for
Health Care Needs
PFCD in the News
A Key to Achieve Sustainable Development Goals
Dr JS Thakur
MD, DNB, FIPHA, FIAPSM, MNAMS
Professor, School of Public Health, Post Graduate Institute of Medical
Education and Research, Chandigarh
President, World NCD Federation
Dr JS Thakur is one of the pioneers in the area of non-communicable diseases (NCDs), and has immensely contributed to finding innovative solutions to reduce the disease burden. He has also provided recommendations to several South East Asian countries as well as national and state governments in matters related to policy, programme development and advocacy for the prevention and control of NCDs.
During his stint with the WHO, Dr Thakur provided technical support and assistance to the Ministry of Health & Family Welfare, Government of India (GOI) with a focus on strengthening health policy and delivery as well as development of innovative NCD-related programmes.
In his latest role as the President of the World NCD Federation, he is working towards the Global Health Agenda for Universal Health Care for NCDs. The theme of his upcoming First World NCD Congress 2017 is “Preventing Non-Communicable Diseases: Realizing Sustainable Development Goals (SDGs)”.
To know more about his work, the upcoming big event and his viewpoint towards the current healthcare scenario in India, PFCD engaged in a detailed conversation with him.
Q. Why is prioritizing NCDs important in achieving the Sustainable Development Goals (SDGs)? Do you see any progress since they were first adopted in September 2015?
India showed confidence at the 70th World Health Assembly in Geneva that it would achieve the health-related targets under SDG 3, which calls for a significant reduction in global maternal mortality ratio, under-5 mortality, neonatal mortality and premature mortality from NCDs by 2030. The SDG 3 also calls to end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. However, at the same time, it is very important to realize that is a daunting task considering the country’s high disease burden, increasing population and socio-economic diversity. NCDs are a broader developmental issue and is pushing many into poverty due to high out-of-pocket and catastrophic expenditure associated with it. Therefore, the prioritization of NCDs will be a key issue for realizing SDGs. However, looking at the current scenario, the progress is very slow and needs to be accelerated.
Q. Do we have the right policy framework to achieve the NCD-related goals in the SDGs? How does the recently launched National Health Policy 2017 addresses the changing disease profile in the country?
The National Health Policy 2017 was adopted on March 15 this year after being drafted for more than a year and a half. Union Health Minister JP Nadda termed the policy as a huge milestone in the history of the health sector in the country, explaining that it would address the current and emerging challenges necessitated by the changing socio-economic, technological and epidemiological landscape. The policy noted the rising NCD burden and high out-of-pocket expenditure in India, while called for access to the necessary primary, secondary and tertiary services across all segments of the society to ensure delivery of preventive, promotive and curative care.However, the on-the-ground realities mean we are moving forward but at a very slow pace due to poor mechanisms for implementation of the NHP. There are also some areas of concern, including that the proposed increase in government expenditure on health to 2.5% of GDP by 2025 is unlikely to meet the current healthcare needs. Therefore, it is important that we should have a clearly defined implementation and accountability framework to achieve the desired objectives.
Q. Do you see low public health spending and limited healthcare financing options as a major barrier in reducing NCDs burden?
Yes, low public spending on health is a major barrier and a main area of concern. If we look at the percentage of state spending on health, NCDs have much lesser share of spend when compared to the maternal and child health and communicable diseases despite the fact that NCDs account for the highest disease burden and mortality rate. Moreover, the proportion of budget spent on health promotion is also very low. In a recent study in Punjab and Haryana, it was found that only 1% budget of the National Health Mission is going for IEC/health promotion, mostly on printing and health-related advertisement with practically nothing for NCD-related health services.
Q. Should NCDs become a political agenda so that it gets the requisite focus and resources?
Yes, it is a high time that NCDs should come up in the political agenda so that it gets its due share of allocation and resources. On a positive note, health as a social and economic priority has started gaining momentum, especially with the present government, which was not the case before. Meanwhile, the Ministry of Health and Family Welfare is taking some initiatives to address the disease burden.
Q. What are your suggestions for the Government and the private sector in bridging the health workforce gap? Do you see any scope of integration of the workforce for communicable and non-communicable disease?
Workforce is a critical challenge for the National Health Mission as low compensation for the workforce is resulting in making government service less attractive with few takers. The Government of Punjab recently tried to recruit doctors on a permanent position with mere basic salary of about INR 15,000 but half of the posts were left vacant due to the low compensation. I am a strong advocate of a public private partnership in tertiary care services for NCDs, with the Government playing the role of a regulator and facilitator for the same. However, the Government has to be a key player and provider for primary health care services for NCDs.
Q. What is the objective behind launching the World NCD Federation, and where do you see it in the next 5 years?
The World NCD Federation was launched as a professional association on March 7, 2015 with a mission to work for global NCD agenda, Sustainable Development Goals in NCDs and universal health care for NCDs. The objectives of the Federation are to work for the prevention and control of NCDs, mainly diabetes, cardiovascular diseases, chronic respiratory diseases, cancer, stroke, chronic kidney diseases and mental health. As part of our global activities, we plan to organize professional activities, meetings and trainings at global, regional and national level to promote public health approaches in NCDs, build partnership with like-minded professional associations and focus on evidence-based public health interventions so that scarce resources are used optimally in the developing countries. We would also work towards capacity building for surveillance, monitoring and implementation of NCD prevention and control policies and programmes at the regional, national and international level. We would also promote research activities in non-communicable diseases by capacity building and supporting national, regional and international multi-centric studies. The First World NCD Congress is being organized in November 2017 in India, and periodically every 3 years in different parts of the world. We visualize it as a unifying credible force working for global NCD agenda and building partnership in the next 5 years.
Q. The upcoming World NCD Congress 2017 is focused on SDGs. What can we expect from this grand event, and what would be the key takeaways?
The theme of the upcoming First World NCD Congress “Preventing Non-Communicable Diseases: Realizing Sustainable Development Goals (SDGs)” is contemporary and relevant keeping in view SDGs to be achieved by 2030. The event will see participation from several prominent national and international experts, national and international professional associations and universities. The event provides a professional platform to understand different perspectives and develop new ideas of NCDs at a global level. The scientific program of the Congress includes symposia, workshops, invited lectures, plenary sessions, oral papers and posters. Chandigarh Declaration on NCDs will be released at the conclusion of the congress with a concrete action plan.
National Health Policy Recognises and Addresses NCDs Goals in SDGs: Now We Need Implementation
Dr. Sanjiv Kumar
MBBS, MD, DNB (MCH),
MBA, FIPHA, FAMS,
Institute of Health
Management Research, New
Former Executive Director,
National Health Systems
The National Health Policy (NHP) 2017 released in March 2017 has been applauded by many stakeholders in India and outside. However, a policy is only as good as its implementation. The previous policy was adopted in 2002 and it addressed the need of the country at that point of time. The current policy recognises the changed health scenario and builds on the previous two policies. One of the four changes it recognises is emergence of non-communicable diseases as the main cause of morbidity that contributes to 60% of all deaths in India. In the last 15 years, the government has made commitments to various international initiatives such as Sustainable Development Goals and UN High Level Meeting on NCDs . The policy recognises the pivotal role of these commitments and includes strategies to address these. It also includes commitment to progressive achievement of Universal Health Care which is one of the major health targets in Sustainable Development Goals. The policy recognizes the need to halt and reverse the growing incidence of chronic diseases. It recommends setting up of a National Institute of Chronic Diseases including trauma, to generate evidence for adopting cost effective approaches and show case best practices.
The policy will support an integrated approach where screening for most prevalent NCDs with secondary prevention would make a significant impact on reduction of morbidity and preventable mortality. This would be integrated into primary health care network with linkages to specialist consultations and follow up at primary level. The policy includes an emphasis on medication and access for select chronic illnesses on a ‘round the year’ basis would be ensured. Screening for oral, breast, and cervical cancer and chronic obstructive pulmonary disease will be added to screening for hypertension and diabetes. The policy includes more attention to geriatric population which has high prevalence of NCDs (para 4.6 of NHP 2017). The policy also highlights a stronger convergence with AYUSH which will help in addressing lifestyle and newer medicines emerging from research on Ayurveda medicines.
Specific NCDs targets in the National Health Policy 2017
The specific NCDs related targets included in the NHP 2017 are:
To reduce premature mortality from cardiovascular diseases (CVD), cancers, diabetes and chronic respiratory diseases by 25% by 2015.
80% of known hypertensives and diabetic individuals at household level maintain controlled disease status by 2025.
National/state level tracking of selected health behaviour.
Relative reduction of current tobacco use by 15% by 2015 and 30% by 2025.
To reduce prevalence of blindness to 0.25/1000 by 2025 and disease burden by one third from current level.
Reduction in occupational injuries by half from current level of 334/100,000 agricultural workers by 2020.
Health system strengthening initiatives in NHP 2017 to address NCDs
The NHP 2017 included the following health system strengthening and other goals to help address NCDs:
Increase government health expenditure from 1.15% to 2.5% of GDP (it increased only to 1.15 from 0.9% in last fifteen years, despite the goal of 2.5% in the 2002 policy).
Subcentres will be strengthened to become Health and Wellness Centres (HWCs) with additional manpower and expansion of services to address early detection and management of NCDs by strengthening home and community level care through HWCs and expansion of the role of ASHAs
Reduction of 40% in prevalence of stunting of under-five children by 2025. It is well known that malnutrition in early childhood increases the risk of metabolic disorders in adulthood, earlier referred to as Barker’s Hypothesis but a well-established causal relationship with many NCDs.
Engaging other sectors to address NCDs
The policy thrust areas include emphasis on preventive and promotive health which is very important in prevention and management of NCDs by engaging all ministries. The policies build on the commitments of other ministries such as balanced healthy diet and regular exercises, addressing tobacco, alcohol and substance abuse, Yatri Suraksha to address road traffic accidents, reduced stress and improved safety at work place and reducing indoor and outdoor air pollution. The policy also includes ‘Health Impact Assessment ‘of existing and emerging policies of key non-health departments that directly or indirectly impact health. This has been recommended by WHO and has not been implemented in India so far.
Implementation and Accountability for implementing NHP 2017
A policy is only as good as its implementation. Many major recommendations of the last two health policies were not implemented. That happens to policies in other sectors as well. Assigning the implementation work to one of the three departments within the Ministry of Health and Family Welfare – Department of Health and Family Welfare, Department of AIDS Control and Department of Health Research – will reduce the complications and make that particular department accountable. There is also a need to have an implementation monitoring cell which will directly report to the minister about the advancements. The policy does mention implementation framework which has been developed by the Ministry itself. The implementation framework should include clear deliverables and milestones as well as assign clear responsibility and accountability for accomplishing the commitments mentioned in the policy.
Need for a cadre of professionals to manage health programmes
The policy strongly states the need for establishing the Public Health Cadre with qualified and trained health managers to run the national health programmes including non-communicable diseases by specialised health managers. It is high time that these cadres are set up to manage a complex programme like NCDs which involve engaging stake holders outside health sector. The states like Tamil Nadu and Maharashtra which have public health cadres are doing much better in managing NCDs than those without such cadres.
NHP 2017, developed with an extensive consultative and participatory process, is comprehensive in addressing NCDs and related goals. It commits to achieving various goals and targets set in SDGs and UN High Level Meetings on NCDs. However, looking at the past government policies, its implementation remains a concern. An implementation and accountability framework with clearly stated and time bound milestones needs to be developed and monitored by the honorable Health Minister himself and the PMO.
How to Address the Issue of Inadequate Financing for Health Care Needs
India has seen a rapid transition in its health needs over the recent years, with non-communicable diseases (NCDs) now accounting for 53% of disease burden and 60% of deaths. On a positive side, the National Health Policy 2017 has recognized the growing burden of NCDs and the increasing impoverishment due to high out-of-pocket expenditure on health. The policy also envisages to provide complete access to primary, secondary and tertiary services to all segments of the society through preventive, promotive and curative care.
However, what’s worrisome is the low public spending on health which has remained stagnant in the range between 0.9% to 1.2% of GDP from 1990 till present. The WHO World Health Statistics 2015 has also placed India among the bottom countries considering its public spending on health. These under investments in health care result in lower worker productivity and poorer health outcomes. These low levels of expenditures combined with the low penetration of health insurance mean that most Indians purchase their healthcare not through insurance but through direct out-of-pocket payments.
India’s budgetary policies over the past few years show the country’s inclination towards the non-developmental factors, while expenditure on developmental issues such as health and education has persistently taken a back seat. India, with 17.84% of the world’s population, is at high risk of economic implications due to the growing burden and pre-mature mortality because of NCDs.
When talking about the health insurance coverage, over 70% of the country’s 1.3 billion residents are uninsured. This is largely attributed to low enrollment in some of the central and state government health schemes, and the lack of a robust private health insurance market. Moreover, there are also substantial differences across the health insurance schemes regarding the scope of benefits covered. In general, most of the plans do not cover primary care and outpatient medicines, essential components for preventing and managing NCDs.
Considering the country’s diverse healthcare needs and limited financial resources, it is imperative for the Government to consider diverse financing coverage and reimbursement options to meet the health care needs of all citizens, including the expansion of government insurance programs, employer and other private supplemental insurance options innovative financing models, and public-private partnerships.
One such potential solution is a multi-payer approach that would 1) increase enrollment in current government plans, 2) expand government insurance cover to those up the economic scale, reaching the middle class who don’t qualify for government cover but cannot afford private insurance, 3) expand employer/private insurance as supplemental options for those who want to and can pay. This is similar to the approach pursued by Indonesia that recently passed health reform with the intent that all would be covered by 2019.
Adequately financing health care in India will require a significant increase in government and private sector funding and insurance coverage. Fortunately, India has the central and state government health plans in place that could, with the appropriate funding, extend coverage to low income populations currently eligible but not enrolled. Use of a multi-payer approach that expands private health insurance to those not eligible for government programs would transform out-of-pocket spending today to health insurance premiums funded through worker and employer contributions. These contributions would be supplemented by government support to assist lower income working households. The contributions could be paid either through payroll tax or through income related monthly contributions.
To achieve these goals, expanded coverage would also have to address the large differences in benefits covered in existing plans, and the financial coverage limits on what the plans pay. Moreover, the other two financing functions of developing risk pools and approaches for purchasing services would have to be part of the reform.
PFCD in the News
Low Healthcare Spend Worrying
Deccan Herald, June 24, 2017
PFCD Chairman Dr. Kenneth Thorpe says lack of focus on health can have serious implications, not just on the state of the health of people and the misery that it causes, but also in dragging the economy of the country down several notches. What is worse is that the shooting figures of the disease burden and deaths in the country are being fought with dismal figures of public spend on health care. There’s extremely high, about 61% out-of-pocket expenditure, one of the highest in the world, and very low health insurance coverage: only 25% of the population, again one of the lowest in the world. Until the Cabinet cleared the Health Policy, healthcare spend was pegged at a little more than 1% of the GDP. The new policy is aimed at universal health coverage for all and recognises that there are many critical gaps in public health services which would be filled by strategic purchasing.
Getting A Grip On Diabetes
Outlook, July 3, 2017
Experts say the number of diabetics in India is expected to touch 120 million over the next two decades. “Type 2 Diabetes is likely to lead to the biggest epidemic and public health issue in human history, posing a huge barrier to economic development,” says Dr Kenneth Thorpe, chairman, Partnership to Fight Chronic Disease (PFCD). “We need a multi-sectoral approach that fosters partnerships among the government, NGOs and corporate companies,” says Dr Thorpe. “Government policies and incentives such as tax benefits, underwriting and facilitating bank loans—especially to supplement care in underserved and difficult-to-reach areas—are vital to attracting private investments in the healthcare sector,” says Dr Thorpe.
Focus on NCDs : The Earnest Work is Showing Results
ET Healthworld, June 1, 2017
PFCD Chairman Dr. Kenneth Thorpe says good health is one of the most crucial building blocks for human development. If we look at India and its socioeconomic and demographic parameters, the threat looming due to NCDs is alarming. Today, India is world’s fourth largest economy, presenting a multitude of business opportunities for global communities. What truly sets it apart is its demographic dividend of 1.27 billion people and the largest number of young workers in the world. The occurrence of NCDs is mostly in the population under the age of 60 years. Moreover, all forms of NCDs either lead to prolonged treatment cycles or premature death! This is threatening to a nation’s development and its economy as the most productive section of the society is getting significantly impacted.
PFCD in the News
Balancing the Healthcare Act
The Financial Express, May 11, 2017
Dr. Kenneth Thorpe, Chairman, PFCD, says, “India’s unprecedented potential for growth is inexplicably marred by one of its more fundamental traits—falling short in ensuring health and social welfare. Despite positive growth indicators and economic progression, the country has lacked relentlessly in catering to the health requirements of the public, empirically validated in its measly budgetary outlays and inefficient execution in expending allocated funds. A coherent analysis of India’s budgetary policies for health over the past few years paints a dismal picture, with the government persistently prioritising non-developmental factors (such as preservation of country’s defence, law and order, maintenance of the general organs of the government, and so on) over developmental expenditure (items of expenditure designed to promote economic development and social welfare)”.
Hypertension: A Silent Killer
Mint, May 16, 2017
High blood pressure causes 7.5 million deaths worldwide, about 12.8% of the total deaths in a year, according to recent estimates by the World Health Organization (WHO). Hypertension is one of the most common non-communicable diseases in India, says Kenneth Thorpe, Chair of the Partnership to Fight Chronic Disease (PFCD). Building awareness about hypertension, particularly the risks and causative factors, can help tackle the growing disease burden. The risk of hypertension is greater if you’re above the age of 35, overweight, have a family history, mild kidney disease, or are a smoker. Lack of timely diagnosis is contributing to spiralling numbers. It is important to ensure that we put a lid on this dangerous condition.
Cancer Ravages Health as well as Personal Resources in India
Huffpost, May 7, 2017
“You have cancer”. These terrifying words resonate in the ears of someone diagnosed with the dreaded disease. And for their family, the first thoughts are about the affordability of the treatment. In a low-resource country like India, it is one of the most catastrophic Non-Communicable Diseases (NCD) today. The numbers are damning: 12.5 lakh new cases are diagnosed every year and around 28 lakh cases of cancers are prevalent at any given point of time. It also claims lives of about 6.8 lakh patients per year. says PFCD Chairman Dr Kenneth E Thorpe.
Roundtable Discussion on Healthcare Financing
“Innovative Financing Mechanisms to Improve Health Coverage in India”
August 10 2017, New Delhi