Once in a while, the World Bank publishes a visionary and profound report on an important aspect of human well being. A case in point is Unlocking the Power of Healthy Longevity: Demographic Change, Non-communicable Diseases, and Human Capital that was published in Washington D.C. in September 2024. A significant demographic transformation is underway with a rapidly aging population. This transformation is accompanied by a shift in most Low-and Middle-Income Countries (LMIC) such that non-communicable diseases (NCD) are the leading cause of deaths. Most NCD deaths occur in LMICs, and the proportion of all deaths caused by NCDs is likely to surge among them.
Projections suggest a global surge in deaths from 61 million in 2023 to 92 million in 2050, as well as related increases in needs for NCD-related hospitalisation and long-term care. If LMICs can achieve ambitious yet feasible rates of progress, the world could avert 25 million deaths annually by 2050, effectively halving avoidable deaths and meeting the related Sustainable Development Goals (SDG).
Driven by this concern, the World Bank report proposes a healthy longevity initiative (HLI) which takes a life course approach. Briefly, healthy longevity entails sharply reducing avoidable death and serious disability throughout the life cycle, as well as increased levels of physical, mental, and social functioning through middle and older ages, and short period of time before inevitable death (World Bank, 2024). Whether this is feasible in LMICs, especially India, is debatable.
Curiously, it imagines a world in which health care is accessible, doctors and nurses, and para medical staff are competent, honest, and committed to proper patient care, hospitals are well-equipped, the monitoring of patients is systematic and digitised, and there is an awareness of benefits of early detection and treatment of NCDs. While the World Bank report discusses catastrophic health expenses and impoverishment, and inadequate state funding of health care, the chasm between the real world and that which is subsumed in the HLI is much too deep to be overlooked. Indeed, a world without quacks, corrupt doctors, exploitative hospitals, pharmaceutical companies pushing unsafe medicines, and patients with chronic conditions travelling hundreds of miles is rarefied.
The objectives and the strategy of reducing the surge in NCDs must, therefore, be modest and feasible. A recent study by the writers of this article of the growing burden of NCDs in India is a step in this direction.
India’s elderly population, disease concerns
The older population of India is currently the world’s second largest — 140 million people who are aged 60 years and above (compared to 250 million people in China). Moreover, the average annual growth rate of the older population is almost three times higher than the overall population growth rate of India.
The swift descent of the elderly in India (60 years-plus) into NCDs (for example, cardiovascular diseases, cancer, chronic respiratory diseases and diabetes) could have disastrous consequences in terms of an impoverishment of families, excess mortality, lowering of investment and a consequent deceleration of economic growth. Worse, the government has to deal simultaneously with the rising fiscal burden of NCDs and infectious diseases. As a report by The Lancet (2018) emphasises, failure to devise a strategy and make timely investment now will jeopardise achievement of SDG 3 (‘good health and well-being’) and target 4 of a one-third reduction in premature mortality from NCDs by 2030.
NCD morbidity and mortality as shares of total morbidity and mortality have risen steadily in India. In 1990, NCDs accounted for 40% of all Indian mortality and are now projected to account for three quarters of all deaths by 2030. Currently, cardiovascular diseases, cancer, respiratory illness and diabetes are the leading causes of deaths in India, accounting for almost 50% of all deaths (The Lancet, 2018).
Underlying these rising shares are growing risks that are common to several NCDs. These include tobacco use, alcohol abuse, and obesity due to sedentary lifestyles and diets that are getting to be increasingly high in simple carbohydrates and saturated fats. Many populations, particularly in remote rural areas, lack easy or frequent access to primary health-care practitioners who can provide regular screenings for common NCDs.
Impact of social security schemes
The focus here is on diabetes and heart diseases. The writers of this article examine whether participation in social security measures/schemes reduces the prevalence of two specific NCDs followed by whether utilisation of medical services/hospital visits also reduces the prevalence of NCDs. As the India Human Development Survey 2015 is the only all-India panel survey to date, the analysis is based on this survey, supplemented by Longitudinal Aging Study in India (LASI 2017-18) conducted jointly by the International Institute for Population Sciences (IIPS) and Harvard School of Public Health.
Even though pension amounts are meagre, they supplement scanty resources of the elderly poor in covering health-care expenses and thus reduce the NCDs. For treatment of such diseases, hospital visits are unavoidable. However, travel costs, fees and costs of medicines impose a huge financial burden, resulting in large out-of-pocket expenditure and indebtedness and immiseration. While health insurance is useful in restricting the financial burden, this potential is far from fully realised due to limited awareness of eligibility requirements, elaborate documentation, delays in payments, and rejection of claims.
Diets high in refined grain intake cause an increased risk of premature coronary artery disease while rice intake beyond a threshold causes diabetes. Higher intake of red meats such as beef, pork and mutton also contribute to higher risks of diabetes and heart diseases. Besides, a rise in the price ratios of fat-dense foods (sugar and oil) aggravates the risk of both diabetes and heart disease.
Confirming the age gradient, the risks of diabetes and heart diseases are positively associated with age. There are various reasons why diabetes rises with age such as a sedentary lifestyle, high-calorie diet, visceral adiposity, and high genetic predisposition mellitus (type 2) diabetes among Indians at a much younger age and at a lower body mass index (BMI) than the western population.
Of particular importance is the Ayushman Bharat Scheme that aims to provide health insurance coverage to the bottom 40% of households. But its potential has been far from fully realised due to inadequate funding and stringent eligibility requirements, and colossal corruption as revealed by the Comptroller and Auditor General of India (CAG) 2023 (for example, large numbers of ineligible beneficiaries, long delays in empanelment of hospitals, surgeries performed after discharge, and utilisation certificates without signature of competent authorities). However, insurance alone might not be sufficient to achieve access to quality care, which depends on health-care infrastructure, provider availability, and local culture.
Hospital expenses
As private hospitals are notorious for inflated prices of health care, the Supreme Court of India directed the central government in February 2024 to find ways to regulate the rates of hospital procedures. As the Court observed, pricing decisions must be informed by a benchmark for price determination. While price caps do influence actors’ behaviour by making them follow the regulations, these effects tend to be temporary when enforcement mechanisms are weak.
Behavioural changes are no less important, and perhaps also no less challenging. Lack of physical activity and unbalanced high-calorie diet promote weight gains. Obesity is a risk factor for cardiovascular diseases and diabetes and can aggravate risks of cardiovascular disease such as emphysema and bronchitis. Limiting tobacco consumption is expected to have benefits at the individual level but wider reduction in multi-morbidity prevalence requires taxation on unhealthy products.
In conclusion, if and when these policy reforms will be carried out is anybody’s guess.
Raghav Gaiha is Research Affiliate, Population Aging Research Centre, University of Pennsylvania, U.S. Vidhya Unnikrishnan is Lecturer in economics, University of Manchester, U.K. Vani S. Kulkarni is Research Affiliate, Department of Sociology, University of Pennsylvania, U.S.
Published – November 13, 2024 12:16 am IST
