The health transition
Progress on non-communicable diseases should not be benchmarked against sustainable development goals.
NCDs are the leading cause of mortality, globally and in India, and are dominated by cardiovascular diseases, cancers, diabetes and chronic respiratory diseases. So what is true?
In the last week of September, India’s health ministry received the prestigious UN Inter-Agency Task Force Award for “outstanding contribution to the achievement of NCD (Non-Communicable Diseases) related SDG targets”. At the same time, a Lancet paper by the monitoring group, NCD Countdown 2030, contended that India will fall short of the NCD targets pertaining to SDGS. NCDs are the leading cause of mortality, globally and in India, and are dominated by cardiovascular diseases, cancers, diabetes and chronic respiratory diseases. So what is true?
The target set for all countries is to achieve one-third reduction in NCD related mortality between the ages of 30 and 70 by 2030, relative to 2015. The Lancet study reports that high income countries and several upper middle income countries are on course to achieve this target. Lower middle income countries, like India, will need to accelerate the rate of decline to reach the target. Many low income countries are unlikely to reach the target by 2030.
The Lancet paper examines global trends in NCD mortality, using three rates: Mortality between 30-70 years, mortality under 70 years and mortality under 80 years. The first is the indicator linked to the SDGs. The second also measures NCD mortality below 30 years of age, which represents a considerable burden in regions like sub-Saharan Africa. The third regards most NCD deaths before 80 as preventable and premature. The authors rightly argue that the arbitrary selection of the 30-70 year age range limits consideration of, and action against, NCD deaths in the younger and older age groups outside that age band.
These arguments make perfect sense when pleading for broader multi-sectoral policy commitment and extended health system action against NCDs, whose challenge demands a life course perspective — one that is not limited to middle age. Further, the challenge of NCDs will not cease in 2030. As the epidemics mature, the 70-80 age group will pose challenges in many parts of the world. Therefore, the current response should not be a short-term staccato response but one which anticipates and mitigates preventable NCD mortality across the entire 0-80 age range even after 2030.
Use of the three indicators simultaneously to judge progress towards 2030 ignores the varying stages of developmental and epidemiological transition that different countries are traversing. As countries advance along this path, life expectancy progressively rises and the median age of NCD-related mortality will move to a higher age at each subsequent stage. Even within countries, groups with relatively lower NCD mortality in the 30-70 age group (most often women and persons in underdeveloped regions) are likely to move to higher levels of mortality in that age group.
As countries in early health transition (such as sub-Saharan Africa) advance to the next stage by 2030, they will see reduced levels of NCD mortality under 30 but will see NCD mortality rising in the 30-70 age group. A substantial reduction in NCD mortality in the 30-70 age group, by 2030, is not an appropriate performance measure of progress in such populations. Similarly, countries like India which have advanced to the next stage of transition will experience the gender effect of more women facing the risk of dying from NCDs between 30-70 years, even as men will see some NCD deaths shift to the 70-80 year age group. The under-developed states of India will behave like sub-Saharan Africa, transferring under-30 NCD deaths to the 30-70 age group. Inability of these countries to fully meet the 30-70 age SDG target, or reduce the under-80 NCD mortality by a third by 2030, should not be projected as a failure. Much of the impact of current efforts, on reducing the under-80 NCD mortality in India, will come after 2030 even though substantial progress would have been achieved in reducing deaths under 70 by that year. Reducing the 30-70 or under-70 or under-80 NCD mortality should not, therefore, be regarded as an acid test of performance in all countries.
However, age limits should not become a barrier to the provision of NCD care under a Universal Health Coverage (UHC) programme — another major SDG target. Countries keen on achieving the specified 30-70 age related mortality target may tend to focus their resources on preferential care for that group, especially in the provision of life saving clinical services, neglecting other age groups. This militates against equity and undermines the principle of universality. For this reason, reduction of under-80 mortality would be a better measure to judge the overall health impact of UHC.
Therefore, reduction in 0-70 mortality would be a reasonable indicator for tracking India’s progress on NCDs while progress in under-80 mortality would be a good indicator for assessing progress on UHC. It is essential that the government, civil society, academia and media recognise these nuances of health transition which shape the sweep of NCD epidemics as they evolve.
Actions to curb tobacco and alcohol consumption will help reduce future risk of NCD in the under-30 age group, while reducing mortality at all ages, and help create a healthier society which will yield inter-generational benefits well beyond 2030. Actions related to reduction of blood pressure, control of diabetes and provision of competent primary care supplemented by cost-effective specialist clinical care for treatable NCDs will benefit all age groups, with the highest benefits in the 30-80 age group. Energetic implementation of public health policies and NCD-inclusive health services under UHC are what the country needs. India’s efforts in these areas certainly merit the UN commendation. The indicators used to track progress are helpful to further stimulate these actions even if they are not perfect for measuring progress across the broad spectrum of health transition in the relatively short run up to 2030.
The author is President, Public Health Foundation of India. The views expressed are personal
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