CHRONIC NON-COMMUNICABLE DISEASES

1. INTRODUCTIONChronic non-communicable diseases refers to many conditions which are

chronic, lifestyle related and are likely to continue progressively unless intervened. Cardiovascular diseases, stroke, diabetes, cancer, and chronic respiratory diseases accounted for 80% of all deaths due to non-communicable diseases 1. Mental disorders ca0075se a significant morbidity burden. The prevalence of non-communicable diseases and the resulting number of related deaths are expected to increase substantially in the future particularly in low and middle income countries due to population growth, ageing in conjunction with economic transition, changes in behavioural, occupational and environmental risk factors. The growing population and their increased life expectancy compete intensely for the scarce resources and reflected in the basic indicators of the country1. The global burden of non-communicable diseases continues to grow; tackling it constitutes one of the major challenges for development in the twenty-first century.2

2. DEFINITIONAccording to WHO (2011) “Chronic disease is an impairment of bodily

structure or function that necessitates a modification of the patient’s normal life and has persisted over an extended period of time.”

“Chronic diseases as comprise all impairments or deviations from normal, which have one or more of the following characteristics: Permanent, Leave residual disability, caused by non reversible pathological alteration, It requires special training of the patient for rehabilitation ,Maybe expected to require a long period of supervision, observation or care” 3

(The commission on chronic illness in USA -1951)

A non-communicable disease, or NCD, is a medical condition or disease which by definition is non-infectious and non-transmissible between persons. NCDs may be chronic diseases of long duration and slow progression, or they may result in more rapid death. (WHO-2011)

3. MAGNITUDE OF THE PROBLEM3.1 Disease Burden

As per the records of World Health Organization (WHO), 57 million people deaths that occurred in the world in 2008, 36 million (63%) were the result of NCDs.1 Four-fifths of these deaths were low, in middle-income countries, and 29% of those deaths were in people under 60 years, compared with 13% in high-income countries. Without intervention, deaths from NCD are set to increase by 15% between 2010 and 2020, according to WHO predictions, with the biggest increases occurring in the African, Eastern Mediterranean and South East Asian regions.1

NCDs account for more than two fifth (43 per cent) of the DALYs(Disability-Adjusted Life-Years) and among this group cardiovascular diseases, diabetes and cancer together accounted for 40 per cent of the NCD related DALYs in India.4,,5,6

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3.2 Socio Economic BurdenIn India, the economic impact of deaths due to cardiovascular diseases,

stroke and diabetes were estimated at 8.7 billion dollars in 2005, with a projected rise of 54 billion dollars by 2015.1 In India, the estimated annual income loss on account of NCD was 258 billion to 1 trillion in 2004. Of this, 32% was attributable to cardiovascular diseases, 18% to chronic respiratory diseases and 15% to diabetes. It is believed that non-communicable diseases (NCDs) are completely eliminated; the estimated GDP (Gross Domestic Product) in a year would have been 4-10 per cent higher2.

4. GAPS IN NATURAL HISTORY There are many gaps in our knowledge about the natural history of chronic diseases. These gaps cause difficulties in aetiological investigations and research. Those are:3

Absence of known Agent: In most of NCDs the cause is not known. Multifactorial Causation : There will be many causes, in absence of causative

agents, risk factors are studied as follows: An attribute or exposure that is significantly associated with

development of disease. If determinant is modified by intervention, it reduces possibility of

occurrence of disease. Risk factors can be causative, contributory or predictive. They can be modifiable or non modifiable They can be individual or community risk factors Epidemiological studies are needed to identify risk factors

Long Latent Period : It is the period between the first exposure to suspected cause and the eventual development of disease. This makes difficult to link suspected causes with outcomes.

Indefinite onset of the Disease : Most NCD are slow in onset and development. Distinction between diseased and non-diseased may be difficult to establish.

5. MAJOR CHRONIC NON-COMMUNICABLE DISEASESAs per WHO (World Health Organization) Working Group, the following disease conditions are the major chronic non-communicable diseases.7

Diabetes Mellitus Cardio-Vascular Diseases Cancer Stroke Chronic Respiratory Diseases (CRD) Mental and Behavioural Disorders

5.1 DIABETES MELLITUSIt is a chronic disorder characterized by raised blood sugar levels that occur

when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Uncontrolled diabetes may lead to serious damage to many of the body's systems, especially the nerves and blood vessels.3

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5.1.1 Magnitude of the Problem Disease Burden The number of diabetics in India is expected to increase from 51 million in

2010 to 87 million by2030.8

Currently 39.5 million people in India have pre diabetes, and of them, seven million people will develop diabetes every year.9

Epidemiological studies indicate that the prevalence of diabetes is higher in urban India, and is increasing faster as compared to the rural population.

Socio Economic Burden An individual with diabetes may spend around twice as much on medical care

compared to a contemporary individual without diabetes. While the mean direct annual cost for outpatient care for all patients with

diabetes in India was Rs 4724/-, those without complications had an 18% lower cost.5

Being diagnosed with diabetes is traumatizing and imposes a long term psychological burden on the individual and the family.

Complications from diabetes, such as diabetic neuropathy, amputations, renal failure and blindness are the major causes of disability.

5.2 CARDIO-VASCULAR DISEASESCardio Vascular Diseases (CVDs) are a group of disorders of the heart and blood vessels, it includes the following: 10

a) Coronary Heart Disease (CHD) b) Cerebro Vascular Disease c) Peripheral Arterial Disease d) Rheumatic Heart Disease e) Congenital Heart Disease f) Deep Vein Thrombosis and Pulmonary Embolism

Here, we will deal exclusively with Coronary Heart Disease (CHD), the most important cause of deaths among cardiovascular diseases.

5.2.1 CORONARY HEART DISEASE (CHD) Coronary Heart Disease is a disease of blood vessels in which arteries that provide blood

and oxygen to the heart muscles are get narrowed or even completely blocked that leads to heart attacks.3

5.2.1.1 Magnitude of the Problem Disease Burden

Coronary Heart Disease is the leading cause of death in India, accounted 2.25 million deaths in 2010 (excluding stroke) and is projected to reach 2.94 million deaths in 2015 5,11

Socio-economic burdenIndia is estimated to have lost 8.7 billion dollars in 2017 because of Coronary heart disease.5

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5.3 CANCERCancer is a term used for disease in which cells of the body grows and divide in an

uncontrolled manner to produce abnormal cells. These cancer cells invade adjoining parts of the body and may spread to other organs. This process of spread to distant organs is called metastasis which is a major cause of death in cancer. Cancer can affect any part of the body. Cancer is also known as malignancies and neoplasms.1, 3

5.3.1 Magnitude of the Problem Disease Burden

Cancer is one of the leading causes of death among adults in India, annually accounting for about 9, 49,000 new cases and 6, 34,000 deaths in 2010. 12

Socio Economic BurdenMales with cancer are likely to have a 43.9% greater likelihood of imposing catastrophic

expenses on their households and a 24% greater likelihood of impoverishing their households than matched counterparts without cancer. They also use more health care services in both the public and the private sectors. Females with cancer also report higher health care use, health spending, and risks of impoverishing their households than their matched counterparts.2

5.4 STROKEA stroke is caused by the interruption of the blood supply to the brain, usually

blood vessels may rupture or blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissues. A Transient Ischemic Attack (TIA) is a transient episode of loss of brain function caused by blockage of blood flow in the arteries of the brain. The symptoms of TIA improve within 24 hours.3

5.4.1 Magnitude of the Problem

Disease Burden Strokes are estimated to have caused 1.45 million cases in India during 2010

with projected increase to 1.67 million cases in 201513.

The average age of stroke patients in India is seen to be less than that in developed countries and affects the most productive part of their life.

Many of the stroke patients are left with permanent disability. Common disabilities include pain, stiffness, depression, memory loss, and difficulty in speaking and understanding.

Socio Economic BurdenIndia is estimated to have lost 8.7 billion dollars in 2005 because of stroke and projected to lose 54.0 billion dollars in 2015 due to this disease.5, 13.

5.6 CHRONIC RESPIRATORY DISEASES (CRD)Chronic respiratory diseases (CRD) include a large number of chronic

diseases of the lungs and respiratory systems. The most common Chronic Respiratory Disease which causes an enormous health burden is chronic obstructive pulmonary disease (COPD). COPD is a continuously progressive disease which leads to marked breathing disability ultimately resulting in premature deaths.14

5.6.1 Magnitude of the problem

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Disease Burden According to the Million Deaths Study (2001-2003), the chronic respiratory

diseases were the second commonest cause of death in Indians in the age group of 25-69 years, after cardiovascular diseases15.

The Disability Adjusted Life Years (DALY) lost due to Chronic respiratory diseases (CRDs) was estimated as 3% of 291 million for all NCDs, i.e. around 8.7 million DALYs in 200516.

Socio Economic Burden The annual cost of treatment of COPD has been estimated to be over Rs.

35,000 crores for the year 2011 and over Rs. 48,000 crores for 201617. Psychological and economic burden is imposed on the families due to

progressive disease disability, frequent exacerbations and hospitalizations. COPD in children poses psychological stress for themselves as well as their

parents and results in poor educational performance.

5.7 MENTAL AND BEHAVIOURAL DISORDERSMental and behavioural disorders are conditions that lead to disturbances in

thinking, feeling, emotions, reactions, intelligence, judgment, decision making and behaviour. The presence of these disorders can impair a person's ability to deal with ordinary demands of the life. These conditions are varied in nature and intensity, ranging from minor disorders such as anxiety, depression, simple phobias, and substance abuse such as alcohol, tobacco to severe forms of illness like as schizophrenia, mood disorders and severe mental retardation. The disorders may also be specific to certain age groups (children & elderly) and with specific reference to some situations (aftermath of disasters).18

5.7.1 Magnitude of the Problem

Disease Burden As per WHO, the global prevalence of mental and behavioural disorders are

estimated to be about 10% and they constitute four of the 10 leading causes of disability (15% of DALYs lost) with one in four families suffering the burden.1

About 1, 50,000 deaths are estimated to occur due to suicides in India every year. Apart from greater vulnerability and socio-cultural attitudes, people from lower income levels also do not have access to quality mental health care. The age group of 15-49 years are affected with most mental disorders except those disorders specific to pediatric and geriatric age groups.19, 20

Socio-Economic Burden Apart from direct costs of travel, medication, hospital visits and rehabilitation,

the indirect productivity losses due to mental disorders are more significant. Mental disorders cause significant amount of disabilities in the affected, which

affect their education, occupation, married life, social and recreation activities and interfere in productivity and quality of life21.

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Selected Mental Health, Neurological and Behavioural Disorders: All India estimates for the year 2010 shown in figure-1 21

6. OTHER CHRONIC NON COMMUNICABLE DISEASES INCLUDE 23,07

Chronic Kidney Disease Congenital Diseases Iodine Deficiency Disorders Oro-Dental Diseases Injuries Dementia Musculo Skeletal Disorders Disasters

Hearing Loss Autism Spectrum Disorders (ASD) Fluorosis Hereditary Blood Disorders Burns Epilepsy Geriatric Disorders

7. RISK FACTORSThe underlying socio-economic, cultural, political and environmental

determinants for NCDs include Globalization, Urbanization and Population ageing. The risk factors for NCDs are classified in terms of their amenability to interventions as modifiable risk factors, non-modifiable risk factors and intermediate risk factors. 3,4

7.1 Modifiable Risk Factors Tobacco Use

Tobacco consumed in any form, whether smoked or chewed and second-hand tobacco smoke exposures are associated with adverse health effects. It is associated with cardiovascular diseases, cancers, chronic respiratory disease, and other communicable and non communicable diseases. Alcohol Consumption

There is a direct relationship between higher levels of alcohol consumption and rising risk of cardiovascular diseases and some liver diseases. Heavy episodic drinking (binge drinking) is especially associated with cardiovascular diseases.

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Consumption of Fruits, Vegetables and Processed FoodInadequate consumption of fruits and vegetables (less than five servings /day)

increases the risk for cardiovascular diseases, stomach cancer and colorectal cancer. The consumption of high levels of high-energy foods, such as processed foods that are high in fats and sugars, promotes obesity. Consumption of > 5 gram of dietary salt/ day predisposes to higher blood pressure levels and increased risk of cardiovascular diseases. Consumption of high amounts of saturated fats and transfat increases the risk of coronary heart disease and diabetes. Physical Inactivity

Low physical activity is an important cause of overweight and obesity. Participation in 150 minutes of moderate physical activity for every week or equivalent activity is estimated to reduce the risk of cardiovascular disease, diabetes, breast and colon cancer, and depression. Poverty

Poverty means that there is less purchasing power in the homes. This low purchasing power results in compromising on the choices that is made at the household level. This results in major health-damaging behaviors such as tobacco use, harmful use of alcohol, inadequate consumption of fruits and vegetables and preferential use of less expensive and unhealthy foods among the vulnerable and marginalized groups of people. Environment

Environmental risk factors are contributing to the NCD’s’ like as Air Pollution, water Pollution, Occupational Hazards and Exposure to Radiation. Inadequate Health Services

Failure and inability to obtain preventive health services such as screening, regular follow up are major predisposing factors to the NCDs. Also, some late diagnosis of disease conditions, untreated infections may lead to carcinomas. Stress Factors

Acute and chronic stresses such as Homelessness, Stressful work conditions and Situations as in Natural and Manmade Disasters are major causes for many physiological and psychological disorders.

7.2 Non modifiable risk factors

The Risk factors, which cannot be modified are called as non-modifiable risk factors, as follows: Age: Elderly and children are the vulnerable group to get the diseases basically. Sex: There will be some difference between the disease ratios among the

gender. Family History of Genetic Factors: Genetic factors are major risk factors which

cannot be modified. Personality: Individual personality may contribute in development of the non

communicable diseases.

7.3 Intermediate Risk Factors Obesity and Overweight (overweight (BMI>=25) or Obese (BMI>=30))

Physical inactivity and inappropriate nutrition are directly reflected in the growing burden of overweight in the Indian population predominantly in the urban areas. Central obesity is an important risk factor for diabetes and appears to better predict the risk of diabetes among Indians in Asian region.

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Hyperlipidemias(>200 mg/dl)People with hyperlipidemias (most often high cholesterol) are at increased risk

of ischemic heart diseases, stroke, and other vascular diseases. Raised blood Pressure (>120/80 mmhg)Raised blood pressure is considered as modern life style disorder in the

present scenario. It is a major risk factor for cardiovascular diseases. Raised Blood Glucose(>120 mg/dl)Raised blood glucose increases the propensity to macro vascular and micro

vascular complications, such as cardiovascular diseases, cerebro vascular disease, retinopathy, nephropathy, neuropathy and diabetic foot, all of which account for considerable mortality and morbidity8. IMPACT ON ECONOMIES, HEALTH SYSTEMS, HOUSEHOLDS AND INDIVIDUALS

The impact of the mounting NCD challenge cannot be fully understood without considering the broad range of direct and indirect effects on economies and health systems, as well as on the affected individual and his or her household. These effects, in aggregate, drive economic and human development outcomes including the decreased country productivity and competitiveness, greater fiscal pressures, diminished health outcomes, increased poverty and inequity, and reduced opportunities for society, households and individuals 2,5,14

Impact on Economies Reduced labor supply and outputs Additional costs to employers Lower returns on human capital investments Lower tax revenues Increased public health and social welfare expenditures

Impact on Health systems Increased consumption of NCD-related healthcare High medical treatment costs (per episode and over time) Demand for more effective treatments (e.g., cost of technology and

innovation) Health system adaptation and costs. (e.g., organization, service delivery,

financing)Impact on Households and Individuals

Reduced well-being Increased disabilities Premature deaths Household income decreases, or impoverishment, Savings and assets loss Higher health expenditures, including catastrophic spending

9. PREVENTION OF NON-COMMUNICABLE DISEASES Prevention of NCDs can be done through following method 3,11

Primordial prevention: Through the prevention of emergence or development of risk factors in the population or in the countries in which they have not yet appeared. Efforts are directed towards discouraging children from adopting harmful life styles.

Primary prevention: Action taken prior to the onset of disease which removes the possibility that the disease will ever occur. Effort will be done through health promotion and specific protection

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Secondary prevention: Action which halts the progress of the disease at its incipient stage and prevents complications.

Tertiary prevention: All measures available to reduce impairments and disabilities minimize suffering due to departure from good health and promote patient’s adjustment to irremediable conditions. Effort will be done through disability limitations and rehabilitation

10. GLOBAL AND NATIONAL EFFORTS TOWARDS “NCD” CONTROL IN INDIA

10.1 Innovation to Counter NCD.The World Health Assembly held in the month of May 2012 set a global target

to reduce deaths under 70 years of age due to NCD by 25% before 2025. Innovation will be essential to achieve this target; the innovations may act on the biological risk factors of NCD such as hypertension, high blood sugar, high blood lipids and obesity, on the behavioural risk factors like as tobacco, poor diet, physical inactivity and the harmful use of alcohol or on the social determinants of NCD. The types of innovation WHO identified are: biological and information technology, medical devices, changes in the workforce, greater involvement of patient’s and civil society and organizational innovations. 22

10.2 Drivers of Innovation DiffusionTo have impact, innovations must diffuse widely, but within health systems

they all too often do not diffuse.Drivers of diffusion include: Professional discussion by stakeholders like market, consumers, government, international organizations and business.

However, there are some barriers, those are: Existing healthcare providers and professional hierarchies might resist

changes that threaten their dominance and income Fears that innovations will not be safe and the risk that financial benefits

from the innovation might occur in a different budget from that of the costs, and might take some years to become visible and be appreciated.

India has shown its commitment to prevention and control of NCDs. India was among the first signatories to the Framework Convention for Tobacco Control (FCTC) and has endorsed the Global Strategy on Diet, Physical Activity and Health. The Government of India has implemented legislations and policies in accordance with the FCTC.22

10.3 Ongoing National Programmes for prevention & Control of Non Communicable Diseases:

Government of India had supported the States in Prevention and Control of NCDs through several vertical programmes. They are as follows: 23

National Cancer Control Program (1975) National Blindness Control Program (1976) National Mental Health Program (1982) National Iodine Deficiency Disorders Control Program (1986) National Tobacco Control Program (2007)

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Trauma Care Facility on National Highways(9th Plan) National Deafness Control Program (2006-07) National Program for Prevention and Control of Fluorosis (2007-08) Pilot Project on Oral Health (2007-08) National Program for Prevention & Control of Cancer, Diabetes,

cardiovascular diseases (CVD) and Stroke (2010-11) National Program for Health Care of the Elderly (2010-11) Pilot Program for Prevention of Burn injuries (2010-11) Up gradation of Department of Physical Medicine & Rehabilitation (PMR) in

Medical Colleges (2010-11) Disaster Management/Mobile Hospitals (2010-11) Organ and Tissue Transplant biomaterial centers (2010-11)

11. WHO BEST BUYS FOR CONTROL OF NON-COMMUNICABLE DISEASES

World Health Organization has led global efforts to address NCDs through development of different instruments. Those are Population level interventions and Individual Level Interventions.7,23,24

11.1 Population level InterventionsNCDs can best be addressed by a combination of primary prevention, targeting

whole population, by measures that targeting high-risk individuals and by improved access to essential health-care interventions for people with NCDs.

Enforcing bans on tobacco advertising, promotion and sponsorship. Raising taxes on tobacco. Strong legislative effort for tobacco control: Government of India had ratified

the National Anti-Tobacco Legislation in 2007, which bans smoking in public places throughout the country.

Restricting access to retailed alcohol. Enforcing bans on alcohol advertising. Raising taxes on alcohol. Promoting salt reduction in the community through awareness generation

and reducing salt content of processed foods. Regulatory mechanism for fruits and vegetable prices. Promoting public awareness about diet (Replacing trans-fat in food with

polyunsaturated fat) and physical activity, through mass media. Comprehensive policies on food production, nutrition, marketing, and

transport to promote primordial prevention of CVDs. (Cardio-vascular diseases)

Modifying the environment (building the play grounds & parks for relaxation). Promoting use of cleaner alternate fuels in kitchens. Improved monitoring and strict enforcement of air quality norms in urban as

well as rural areas. Public education on air-quality and measures to reduce air pollution. Developing alternative financing models that protect citizens from the

catastrophic financial impact of chronic diseases including CVDs.(Cardio-vascular diseases)

A major initiative in CVD control has been the launch of the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke [NPCDCS) in 2010. This envisages early diagnosis,

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risk reduction, and appropriate management of these diseases at primary health care level.

Protection from occupational carcinogens Protection against HBV( Hepatitis B virus) and HPV (Human papilloma virus)

by vaccinationThe National Cancer Control Programme was revised in 1984. This programme has

now been integrated into the National Programme for Prevention and Control of Cancer, Cardiovascular Diseases, Diabetes and Stroke since 2011. The data on cancer is collected by hospital and population based cancer registries, collated and published by the National Cancer Registry Programme (NCRP) of the Indian Council of Medical Research (ICMR).

11.2 Individual Level Interventions

Screening and early diagnosis of disease in all health care settings Individual health education towards prevention of diseases and promotion of

health. Counselling, drug therapy, specific treatment and rehabilitations.

12.STRENGTHENING HEALTH SYSTEMS TOWARDS NCDs IN INDIA23

Development and implementation of clinical practice guidelines and standards at different levels of health care centre.

Adequate supply of drugs at all health care centre Providing better counseling services for lifestyle changes including cessation

of tobacco use and Public education about diabetes and its complications. A multi-sectoral approach beyond the health sector is required to curb the

diabetes epidemic, for example, labeling of food items with nutrition facts, making healthy food options available at schools and workplaces, compulsory physical activities in educational institutes.

Training of primary health care staff in management of chronic respiratory diseases.

Cancer awareness and screening for cervical, breast and oral cancer should be introduced at the primary health care level in the National Rural Health Mission (NRHM).

Diagnostic and management facilities for above said cancers should be introduced at the district level.

Specialized treatment services for cancers in medical colleges and other hospitals. Home support for palliative and rehabilitative services should be introduced at the

primary health care level. Training of doctors and nurses to identify and manage all kind of diseases Establishment of vascular (cardiac and stroke] units at district level and

medical college hospitals. Establishment of ambulance and referral systems. Greater investment in infrastructure and manpower to improve capacity for prevention

and control of NCDs. Accreditation to improve quality of care at different levels, including private sectors.

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12.1 National Effort towards Mental Health Problems24

Policy & Health System Interventions

Revised District Mental Health Programme incorporating public health approaches to cover all districts

Implementation of the revised Mental Health Care Act to facilitate rights of the mentally ill along with strengthening of implementation

Capacity building of policy makers and programme managers to enhance mental health care delivery, implementation, monitoring and evaluation

Human resource development with training of doctors, health care workers and peripheral workers

Expanding the role of mental hospitals and medical college psychiatry units to integrate preventive, curative, promotive and rehabilitative services along with manpower development and research

Strengthening educational and employment opportunities for those who have recovered from mental disorders

Integrating mental health with other activities in health sector with AYUSH systems of medicine, and other related sectors

Involvement of NGOs in stigma reduction, rehabilitation, public awareness building and advocacy issues.

India has a National Mental Health Programme for more than 25 years with curative, preventive, promotive and rehabilitative components covering policy and programme issues. The programme is at present being implemented across 100 districts and is likely to be expanded to the entire country during 2012-17.

13. SPECIFIC ACTIONS BY DIFFERENT STAKEHOLDERSThere are some specific actions to be performed by the stakeholders in the

society to prevent and control of NCDs.7

Governmenta. Revision of National Health Policy to address NCDs or formulate a NCD

Policy.b. Setting-up an Inter-Ministerial Group or Group of Ministers to address critical

inter-sectoral issues (urban development, road transport, agriculture, food processing, finance, human resource development, information and broadcasting, industry, trade & commerce, communications)

c. Assessing health impact of all major developmental programmes d. Adopting regulatory and fiscal measures to influence dietary behaviour

(regulation of sugar, salt and transfat in food products) tobacco and alcohol use

e. Creating a National Health Promotion Foundation to co-ordinate and catalyze all activities related to NCDs

Individualsa. Adopting healthy lifestyle and motivating others to do so.b. Being an aware and responsible citizen - following regulations and insisting

others also to do soc. Monitoring and changing the behaviour of children (watching TV, diet,

physical activity) in the family.

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Communities/Schools/Workplacesa. Creating an healthy environment for adoption of healthy behaviorb. Supporting implementation of regulationsc. Creating and maintain facilities for physical activity / healthy dietsd. Incentivizing good behaviours and disincentives the inappropriate behaviors.

Health Professionalsa) Taking leadership role at individual level as well as community level to

advocate lifestyle changesb) Developing / implementing guidelines for prevention and management of

NCDsc) Strengthening the capacity of health workforce to address NCDsd) Conducting appropriate epidemiological, operational and translational

research to address NCDs.

Non Governmental Organizationsa) Mobilizing the community to adopt Healthy Lifestylesb) Change the societal "norms"c) Being a watchdog and monitor implementation of regulations.

14. PLAN OF ACTION TO PREVENT AND CONTROL OF NCDS DURING

12th PLAN A comprehensive approach would be required for both prevention and management of NCDs in the country. It is proposed to continue ongoing efforts and introduce additional programmes to cover important NCDs for public health importance through following key points7,24

14.1 KEY COMPONENTS OF NCD PREVENTION AND CONTROL PROGRAMMES INCLUDE: Formulation and implementation of comprehensive policies and programmes to

address NCDs. Strengthening of health system in terms of human resource availability,

development of standard management guidelines, training at all levels of human resources, ensuring availability of drugs and equipments. The role of private sector is also important in this regard.

As NCDs require lifelong treatment and often require costly health care interventions, a sustainable and equity-based health financing system needs to be set up. This is required to ensure universal coverage for prevention and control of NCDs.

Currently, the surveillance efforts and information system in the country are disjointed, ad-hoc and inadequate. There is an urgent need to bring them under a common umbrella and integrate it with ongoing disease surveillance systems.

14.2 I M PL E M E NTATION

To ensure long term sustainability of interventions, the programmes would be built within existing public sector health system and wherever feasible introduce public private partnership models. Following will be major components of NCD programmes:

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Primary Health Care includes Health promotion, screening , basic medical care, home based care & referral system (to be integrated with NRHM-National Rural Health Mission)

Strengthening District Hospitals for diagnosis and management of NCDs including rehabilitation and palliative care, NCD Clinic, Intensive Care Unit, District Cancer Centre, Dialysis services, Geriatric Centre, Physiotherapy Centre, Mental Health Unit, Trauma & Burns Unit, strengthening of facilities for Orthopaedic, Oro-dental, Eye and ENT Departments, Tobacco Cessation Centre, Obesity Guidance Clinic.

Tertiary Care for advanced management of complicated cases including radiotherapy for cancer, cardiac emergencies including cardiac surgery, neurosurgery, organ transplantation.

Emergency medical care and rapid referral system including Highway Trauma Centres and 108 emergency services.

Health Promotion & Prevention includes legislation, population based interventions, Behaviour Change Communication using mass media, mid-media and interpersonal counselling and public awareness programmes in different settings (Schools, Colleges, Work Places and Industries).

14.3 ESTI M ATED BUDGET DURING 12 TH FIVE YEAR PLAN

It is envisaged that for comprehensive and sustainable programme to prevent, control, manage important non-communicable diseases and key risk

factors across the country, a large investment would be required during the 12th

Plan, Rs. 58,072 crore would be required over the period of 2012-17.

14.4 EXPECTED OUTCO M ES

The programmes and interventions would establish a comprehensive sustainable system for reducing rapid rise of NCDs, disability as well as deaths due

to NCDs. Broadly, following outcomes are expected at the end of the 12th Plan are:

a) Early detection and timely treatment leading to increase in cure rate and survival.

b) Reduction in exposure to risk factors, life style changes leading to reduction in NCDs.

c) Improved mental health and better quality of life.d) Reduction in prevalence of physical disabilities including blindness and

deafness.e) Providing user friendly health services to the elderly population of the countryf) Reduction in deaths and disability due to trauma, burns and disasters.g) Reduction in out-of-pocket expenditure on management of NCDs and thereby

preventing catastrophic implication on affected individual and families.

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15. AYUSH and NCDsThe representative of Government of Sikkim, shared their experience of

controlling NCDs through AYUSH (Ayurveda, Yoga, Unani, Siddha and

Homeopathy) intervention. They also stated that they have identified 72% of disease of hypertension in a particular village has been considerably brought down through the AYUSH intervention. Govt of India, and Department of AYUSH with state health secretaries on 25.4.2012 determined that AYUSH professional and facilities to be geared up for assisting national health programmes under NPCDCS (National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disorders). Also, they said Training and IEC (Information Education Communication) material on preventive & promotive role of AYUSH system in controlling NCDs would be prepared by Department of AYUSH for sharing with States.25

16. GLOBALIZATION AND ITS IMPLICATIONS FOR HEALTH CARE AND NURSING PRACTICE Globalization describes the increasing economic and social interdependence

between countries. Nursing is challenged with responding to the changing health needs of the global population that have arisen as a result of globalization.26

The World Health Organization (WHO) Global Forum for Government Chief Nursing and Midwifery Officers (GCNMO) took place on May 16-17 th, 2012, while the Triad meeting, Nursing leaders discussed how to strengthen the role of nursing and midwifery in NCDs. Leaders agreed that in order to tackle the issue of NCDs, continuous development is needed in nursing education, research, and nursing leadership in policy. All nursing leaders fully agreed that the issue of NCDs should be mediated by nurses using an upstream approach rather than a downstream approach. In the downstream approach, nurses treat a problem that is already occurred. In the upstream approach, nurses prevent the consequences by using their skills and knowledge to educate the patient and prevent the disease from occurring in the first place.27

17.0 CONTRIBUTION TOWARDS PREVENTION AND TREATMENT OF “NCDs” BY NIMHANSNIMHANS is one of the exceptional foundations rendering wide-range care towards non communicable diseases through following activities

Preventive, Promotive Rehabilitative health care has been provided through the multidisciplinary team members includes Nurses, Psychiatrist, and Neurologist, Neurosurgeons, Psychologist, Social workers, Yoga therapist, Ayurvedic personnel and supportive workers from all the departments.

Community health unit is providing its continuous extraordinary comprehensive services through the organizational employees and graduate and post graduate students towards NCDs and other diseases in community.

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The epidemiology department is giving tremendous support by doing the surveillance among all the NCDs. Several research projects with focus on risk factors (tobacco, alcohol, stress, physical inactivity, unhealthy diet, along with large number of mental health behaviours) have been completed in the department. The findings have resulted in developing intervention programmes and follow-up studies at different levels.

Continuous ongoing research work has been performed by all departments towards NCDs especially, stroke, epilepsy, psychiatric disorders, other neurological and neurosurgical disorders, injuries, genetic disorders and psychosocial problems in all age groups.

Health education and publication departments are delivering incredible, effort towards NCDs through awareness programs.

NIMHANS is one of the major collaborators with Fogarty Indo-US Training Program on Chronic Non-Communicable Diseases (CNCD) Across Lifespan to reduce the training gap and increase research capacity for CNCDs,

NIMHANS contributes its enormous effort on Health Policies and National Health Programs to prevent and control NCDs, especially District and National Mental Health Programs.

18. RESEARCH ABSTRACTDecola P et al (2012) highlighted in their stratified representative research

survey of 1600 nurses in eight countries were conducted to understand better, how nurses perceive their roles in addressing risk factors associated with NCDs as well as the types of supports required in order to facilitate this work. The study also explores nurses' changing views of the profession and their practice environment. Key findings included that 95% of nurses wanted to use their knowledge, skills and time to educate individuals on the threat and prevention of NCDs, but workload, time constraints and their perception towards the job of nursing hinder them from achieving their potential.28

19. CONCLUSION

Within a couple of decades, NCDs are poised to dominate the health care needs in most low and middle income countries and to exact a significant human and economic toll on countries and their population. Despite the magnitude of the challenges, there is considerable scope for action. Improved health care, early detection and timely treatment is another effective approach for reducing the impact of NCDs. Health systems need to be further strengthened to deliver an effective, realistic and affordable package of interventions and services for people with NCDs.

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