On November 14, 2017, the India State-level Disease Burden Initiative, which is a joint initiative between the Indian Council of Medical Research (ICMR), Public Health Foundation of India (PHFI), and Institute for Health Metrics and Evaluation (IHME) in collaboration with the Ministry of Health and Family Welfare, Government of India along with experts and stakeholders associated with over 100 Indian institutions, released the first comprehensive set of state-level disease burden, risk factors estimates and trends for each state in India for informed health planning to reduce health inequalities amongst states in India. These estimates are based on analysis of all identifiable epidemiological data from India over quarter of a century39.

The report provides the first comprehensive set of findings for the distribution of diseases and risk factors across every state of India from 1990 to 2016, utilizing all available data and in close engagement with many leading health scientists of India. Through an elaborate process all available data sources to estimate disease burden in every state and union territory of India were identified and accessed. These included censuses, vital registration, Sample Registration System, large-scale national household surveys, other population-level surveys and cohort studies, disease surveillance data, disease programme-level data, administrative records of health services, disease registries, and a wide range of other studies conducted across India. Data was included in the analysis if it met quality and inclusion criteria. The burden from 333 disease conditions and injuries and 84 risk factors were computed for each state of India as part of the Global Burden of Disease Study 2016.

In order to understand the specific disease trends amongst various states at different levels of epidemiological transition, the states were divided into groups based on the ratio of Disability Adjusted Life Years (DALYs) from infectious and associated diseases to DALYs from non-communicable diseases and injuries combined. Variations of diseases and risk factors were analyzed between groups of states and between individual states that are relevant for a more informed specific health system response in each state.

The report shows a rising burden of non-communicable diseases in all states. The percentage of most of the major non-communicable disease groups to the total disease burden has increased all over India since 1990, including cardiovascular diseases, diabetes, chronic respiratory diseases, mental health and neurological disorders, cancers, musculoskeletal disorders, and chronic kidney disease.

The Key Findings of this report are as follows:

  • Life expectancy at birth improved in India from 59.7 years in 1990 to 70.3 years in 2016 for females, and from 58.3 years to 66.9 years for males. However, inequalities in life expectancy continues between states, with the same ranging from 66.8 years in Uttar Pradesh to 78.7 years in Kerala for females, and 63.6 years in Assam to 73.8 years in Kerala for males in 2016.
  • Even though, the per person disease burden dropped by 36% from 1990 to 2016 in India, there was an almost two-fold difference in this rate between the states in 2016, with Assam, Uttar Pradesh, and Chhattisgarh having the highest rates, and Kerala and Goa the lowest rates.
  • The under-5 mortality rate has reduced substantially from 1990 in all states, but there was a four-fold difference in this rate between the highest in Assam and Uttar Pradesh as compared to the lowest in Kerala in 2016, highlighting the vast health inequalities between the states.
  • In 1990, 61% of the total disease burden in India was due to communicable, maternal, neonatal, and nutritional diseases; the corresponding number for which to 33% in 2016. However, the percentage of non-communicable diseases in the total disease burden rose from 30% in 1990 to 55% in 2016, and the percentage of injuries also rose from 9% to 12%.

Infectious and associated diseases, which accounted for more than half of the disease burden in most of the states in 1990, slid down to less than half in all states in 2016, though there were wide variations between the states. Kerala, Goa, and Tamil Nadu show the highest dominance of non-communicable diseases and injuries over infectious and associated diseases, whereas a similar dominance, though reflected, is relatively the lowest in Bihar, Jharkhand, Uttar Pradesh, and Rajasthan.

  • The burden of most infectious and associated diseases reduced in India from 1990 to 2016, but five of the ten individual leading causes of disease burden in India in 2016 still belonged to this group:

Diarrhoeal diseases,

Lower respiratory infections,

Iron-deficiency anaemia,

Neonatal

Preterm birth, and

Tuberculosis.

The range of disease burden or DALY rate among the states of India was nine-fold for diarrhoeal disease, sevenfold for lower respiratory infections, and nine fold for tuberculosis in 2016, highlighting the need for titrating efforts based on the specific trends in each state.

  • The contribution of most of the major non-communicable disease groups to the total disease burden has increased all over India since 1990, including cardiovascular diseases, diabetes, chronic respiratory diseases, mental health and neurological disorders, cancers, musculoskeletal disorders, and chronic kidney disease. In 2016, three of the five leading individual causes of disease burden in India were noncommunicable, with ischaemic heart disease and chronic obstructive pulmonary disease as the top two causes and stroke as the fifth leading cause. The range of disease burden or DALY rate among the states in 2016 was nine-fold for ischaemic heart disease, four-fold for chronic obstructive pulmonary disease, and six-fold for stroke, and four-fold for diabetes.
  • The contribution of injuries to the total disease burden has increased in most states since 1990. The highest proportion of disease burden due to injuries is in young adults. Road injuries and suicides are the leading contributors to the injury burden in India. The range of disease burden or DALY rate varied threefold for road injuries and six-fold for suicide among the states of India in 2016.
  • A group of risks including unhealthy diet, high blood pressure, high blood sugar, high cholesterol, and overweight, which mainly contribute to ischaemic heart disease, stroke and diabetes, caused about 25% of the total disease burden in India in 2016, up from about 10% in 1990. There were large variations between states in the degree to which these risks are rising.
  • While the disease burden due to child and maternal malnutrition has dropped in India substantially since 1990, it is still the single largest risk factor responsible for 15% of the total disease burden in India in 2016. This burden is highest in the EAG states40 and Assam, and is higher in females than in males. The disease burden due to child and maternal malnutrition in India was 12 times higher per person than in China in 2016. Kerala, having the lowest burden in this category, still lags behind China by 2.7 times higher risk.
  • The disease burden due to unsafe water and sanitation has also reduced significantly in India, but this burden is still 40 times higher per person in India than in China. The EAG States and Assam have a particularly high burden due to this risk.
  • The contribution of air pollution to disease burden has remained high in India between 1990 and 2016, with levels of exposure amongst the highest in the world. The burden of household air pollution has decreased during this period due to decreasing use of solid fuels for cooking, but that of outdoor air pollution has increased due to a variety of pollutants from power production, industry, vehicles, construction, and waste burning. The level of exposure to air pollution is highest in the EAG states.

Change in DALYs number and rate for the leading individual causes in India from 1990 to 2016

Footnote

39 http://icmr.nic.in/publications/India_Health_of_the_Nation's_States_Report_2017.pdf

40 Empowered Action Group (EAG) states: A group of eight states that receive special development effort attention from the Govern ment of India, namely, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, and Uttar Pradesh.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.