Comment
Informing NCD control efforts in India on the eve of
Ayushman Bharat
The Government of India recently launched the
ambitious National Health Protection Mission, also
referred to as Ayushman Bharat (which means “bless
India with long healthy life”), Pradhan Mantri Jan
Arogya Yojana, or Modicare. This scheme has two main
pillars: strengthening of universal comprehensive
primary health care and a health insurance scheme to
cover 500 million people in need to reduce catastrophic
out-of-pocket health spending.1,2 The 1·3 billion
population of India has vast socioeconomic and health
diversity across the country. In November, 2017, the
India State-Level Disease Burden Initiative3,4 reported
the first assessment of trends in all of the major diseases
and risk factors in every state of India from 1990 to
2016 using the single framework of the Global Burden
of Disease study, which generated considerable policy
interest.5 Five Articles published today by this Initiative
report further detailed analyses of several major non-
communicable diseases (NCDs) and suicide across the
states of India over a quarter of a century.6–10 This new
evidence can be a useful input for the state-specific
planning of Ayushman Bharat, as disability-adjusted
life-years (DALYs; a composite metric of premature
mortality and morbidity recommended by the Health
Policy of India for disease burden monitoring11) from
NCDs and injuries have together exceeded those
from communicable diseases in every state of India,
contributing 57–86% of the total DALYs among the
states in 2016.4
The Government of India is focused on the need
to address the high and increasing burden of NCDs
and injuries in the country. Briefly, the integrated
National Programme for Prevention and Control of
Cancer, Diabetes, Cardiovascular Diseases and Stroke
established NCD units in each state last year to increase
the momentum for the prevention and management
of major NCDs at the district level, including screening
for high blood pressure and blood glucose and for oral,
breast, and cervical cancers.12 The National Tobacco
Control Programme is facilitating reduction of the
prevalence of smoking in India.6 The Food Safety and
Standards Authority of India last year proposed a tax
and advertisement ban on unhealthy foods.13 The
www.thelancet.com Published online September 12, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32172-X 1
availability of non-polluting cooking fuels for low- Published Online
September 12, 2018
income households has increased under the nationwide http://dx.doi.org/10.1016/
Pradhan Mantri Ujjwala Yojana scheme.14 India also has S0140-6736(18)32172-X
initiatives related to suicide, including the National See Online/Comment
http://dx.doi.org/10.1016/
Mental Health Policy and the Protection of Women S0140-6736(18)32211-6
from Domestic Violence Act.15,16 See Online/Articles Lancet Oncol
2018; published online Sept 12.
The government has planned the establishment of http://dx.doi.org/10.1016/
150 000 health and wellness centres across India to S1470-2045(18)30447-9
provide comprehensive primary health-care services that See Online/Comment
Lancet Oncol 2018; published
would help to deal with NCDs and injuries along with online Sept 12. http://dx.doi.
communicable diseases, as part of Ayushman Bharat.2 org/10.1016/S1470-
2045(18)30563-1
Deliberations on operationalising this effort, led by the
See Online/Articles
Government of India and involving the key decision Lancet Public Health 2018;
published online Sept 12.
makers from all states and a range of other stakeholders,
http://dx.doi.org/10.1016/
point to the acute interest of the government in S2468-2667(18)30138-5
strengthening prevention and management of the full See Online/Comment
Lancet Public Health 2018
range of diseases and risk factors in each state.2 The published online Sept 12.
Government of India is keen to use the latest available http://dx.doi.org/10.1016/
S2468-2667(18)30142-7
evidence to maximise the impact of Ayushman Bharat.
See Online/Articles
In relation to this opportunity, we summarise the key Lancet Glob Health 2018;
policy implications of the findings of the India State- published online Sept 12.
http://dx.doi.org/10.1016/
Level Disease Burden Initiative.6–10 S2214-109X(18)30407-8,
One striking finding is that the age-standardised http://dx.doi.org/10.1016/
S2214-109X(18)30387-5, and
increase in the prevalence of ischaemic heart disease http://dx.doi.org/10.1016/
S2214-109X(18)30409-1
and diabetes, as well as their DALYs, has generally been
highest in the less developed states of India, where
the burden of another major NCD, chronic obstructive
pulmonary disease (COPD), and communicable diseases
is already high.6–8 Among the major risk factors for
ischaemic heart disease, stroke, and diabetes, the
prevalence of high blood pressure, high cholesterol, high
fasting plasma glucose, and overweight has increased
in all parts of India.6,7 The high exposure to ambient
and household air pollution in the less developed
northern states is contributing to the high burden of
COPD in these states, in which the case-fatality rate of
COPD is twice as high as in the more developed states.8
Additionally, ageing of the population is adding to the
increasing burden of NCDs. These findings emphasise
the need for the prevention and management of major
NCDs to receive as much policy attention in these states
as the reduction of the still high burden of communicable
and childhood diseases.
 Comment

State (population) IHD Stroke COPD Diabetes Cancer Suicide

understood, pointing to a knowledge gap that needs to
Bihar (110 million) 12 11 10 16 18 18
be addressed.
India’s policy has focused on health improvements in
Jharkhand (34 million) 15 14 18 15 17 17
the less developed Empowered Action Group states of
Uttar Pradesh (217 million) 16 18 2 14 6 14
Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha,
Rajasthan (75 million) 14 17 1 18 10 15
Rajasthan, Uttar Pradesh, and Uttarakhand, as well as
Assam (35 million) 18 3 6 8 2 11
Assam. The findings in these Articles, that the major
Chhattisgarh (28 million) 13 4 15 9 9 7
NCDs or injuries do not necessarily follow similar trends
Madhya Pradesh (79 million) 11 7 8 10 7 9 among the less developed states or among the more
Odisha (46 million) 17 2 17 12 5 13 developed states (figure),6–10,17 highlight the need to plan
Gujarat (67 million) 6 15 5 13 13 10 for the specific situation in each state.
Haryana (29 million) 3 16 3 6 3 12 India needs to invest in suitable surveillance systems
Telangana (37 million) 9 10 11 11 16 5 to monitor the changing trends in NCDs and injuries,
Andhra Pradesh (52 million) 4 8 9 5 12 3 and their related risk factors, across the country. India’s
Karnataka (66 million) 5 5 4 3 4 1
cancer registry programme is well regarded, but even
this does not cover some large, less developed states
West Bengal (103 million) 10 1 12 17 8 4
and the surveillance of many NCDs and injuries needs
Maharashtra (122 million) 7 6 7 7 14 8
strengthening. Yet another data gap is that only a
Punjab (30 million) 1 12 13 2 11 16
small portion of the deaths in India have their cause
Tamil Nadu (76 million) 2 13 14 1 15 2
medically certified, indicating that the cause of death
Kerala (37 million) 8 9 16 4 1 6
reporting system in India has to be improved to enable
Rank more robust tracking of disease burden. While there are
1–2 3–5 6–9 10–13 14–18
limitations to the findings reported in these Articles
Figure: Rankings of the states of India for the burden of ischaemic heart disease, COPD, diabetes, cancer, and because of data gaps, the detailed composite analyses
suicide, 20166–10,17
Data are shown for the 18 states with a population of more than 25 million in 2016, encompassing 94% of reported using all accessible data over a quarter of a
India’s total population. The states are listed in increasing order of epidemiological transition level in 2016, century are useful to guide the calibration of policy
which broadly corresponds to the Socio-demographic Index level estimated by the Global Burden of Disease
Study.3 The rankings of ischaemic heart disease, stroke, COPD, diabetes, and cancer are for DALY rates, whereas interventions under Ayushman Bharat in different
the ranking for suicide is for death rates. IHD=ischaemic heart disease. COPD=chronic obstructive pulmonary
parts of the country with the aim of reducing health
disease. DALY=disability-adjusted-life-year.
disparities between the states of India.

India has focused on the early detection of breast, oral,
and cervical cancers, but the findings on cancer suggest
that the large numbers of DALYs caused by stomach,
lung, pharynx, and some other cancers also need to
be addressed.9 The wide variations among the states
in the patterns of different cancers over time point
to the need for better understanding of the drivers of
these trends to enable more informed intervention
planning. The Article on suicide10 highlights that this
type of injury is the leading cause of death in young
adults in India aged 15–39 years, that the suicide death
rate among elderly people has increased over the past
25 years, and that India now contributes 37% of the
total deaths by suicide among women worldwide. The
suicide death rate between the states of India varies
by ten times for women and six times for men, but the
factors responsible for these variations are not well
*Balram Bhargava, Vinod K Paul
Indian Council of Medical Research, Department of Health
Research, Ministry of Health and Family Welfare (BB), and
National Institution for Transforming India (VKP), Government of
India, New Delhi 110029, India
balram.bhargava@gov.in
We are employees of the Government of India. Lalit Dandona, Director of the
India State-Level Disease Burden Initiative, helped to coordinate the writing of
this Comment.
Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access
article under the CC BY 4.0 license.
1 National Health Portal, Centre for Health Informatics, Ministry of Health
and Family Welfare, Government of India. Ayushman Bharat Yojana.
https://www.nhp.gov.in/ayushman-bharat-yojana_pg (accessed
Aug 10, 2018).
2 Press Information Bureau, Government of India. National consultation on
Ayushman Bharat: operationalizing health and wellness centres to deliver
comprehensive primary health care. May 3, 2018. http://pib.nic.in/newsite/
PrintRelease.aspx?relid=179095 (accessed Aug 10, 2018).
3 India State-Level Disease Burden Initiative Collaborators. Nations within a
nation: variations in epidemiological transition across the states of India,
1990–2016 in the Global Burden of Disease Study. Lancet 2017;
390: 2437–60.

2 www.thelancet.com Published online September 12, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32172-X


4 ICMR, PHFI, IHME. India: health of the nation’s states—the India State-Level
Disease Burden Initiative. New Delhi: Indian Council of Medical Research,
Public Health Foundation of India, Institute for Health Metrics and
Evaluation, 2017.
5 Ministry of Finance, Government of India. Economic Survey 2017–2018.
http://mofapp.nic.in:8080/economicsurvey/ (accessed Aug 10, 2018).
6 India State-Level Disease Burden Initiative CVD Collaborators. The changing
patterns of cardiovascular diseases and their risk factors in the states of
India: the Global Burden of Disease Study 1990–2016 . Lancet Glob Health
2018; published online Sept 12. http://dx.doi.org/10.1016/S2214-
109X(18)30407-8.
7 India State-Level Disease Burden Initiative Diabetes Collaborators.
The increasing burden of diabetes and variations among the states of India:
the Global Burden of Disease Study 1990–2016. Lancet Glob Health 2018;
published online Sept 12. http://dx.doi.org/10.1016/S2214-
109X(18)30387-5
8 India State-Level Disease Burden Initiative CRD Collaborators. The burden of
chronic respiratory diseases and their heterogeneity across the states of
India: the Global Burden of Disease Study 1990–2016. Lancet Glob Health
2018; published online Sept 12. http://dx.doi.org/10.1016/S2214-
109X(18)30409-1.
9 India State-Level Disease Burden Initiative Cancer Collaborators. The burden
of cancers and their variations across the states of India: the Global Burden
of Disease Study 1990–2016. Lancet Oncol 2018; published online Sept 12.
http://dx.doi.org/10.1016/S1470-2045(18)30447-9.
10 The India State-Level Disease Burden Initiative Suicide Collaborators. Gender
differentials and state variations in suicide deaths in India: the Global Burden
of Disease Study 1990–2016. Lancet Public Health 2018; published online
Sept 12. http://dx.doi.org/10.1016/S2468-2667(18)30138-5.
www.thelancet.com Published online September 12, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32172-X 3
Comment
11 Ministry of Health and Family Welfare, Government of India. National
health policy of India 2017. https://mohfw.gov.in/documents/policy
(accessed Aug 10, 2018).
12 Directorate General of Health Services, Ministry of Health and Family
Welfare, Government of India. National Programme for Prevention and
Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke. http://dghs.
gov.in/content/1363_3_NationalProgrammePreventionControl.aspx
(accessed Aug 10, 2018).
13 Food Safety and Standards Authority of India, Government of India. Report
of the expert group on consumption of fat, sugar & salt and its health
effects on Indian population. New Delhi: Food Safety and Standards
Authority of India, 2017.
14 Ministry of Petroleum and Natural Gas, Government of India. Pradhan
Mantri Ujjwala Yojana: State-wise PMUY connections released.
http://www.pmujjwalayojana.com/released-connections.html (accessed
Aug 10, 2018).
15 Ministry of Health & Family Welfare, Government of India. National Mental
Health Policy of India—New Pathways New Hope. 2014. https://www.nhp.
gov.in/sites/default/files/pdf/national%20mental%20health%20policy%20
of%20india%202014.pdf (accessed Aug 10, 2018).
16 Government of India. The Protection of Women from Domestic Violence
Act. 2005. http://ncw.nic.in/acts/TheProtectionofWomenfromDomestic
ViolenceAct2005.pdf (accessed Aug 10, 2018).
17 Indian Council of Medical Research, Public Health Foundation of India,
Institute for Health Metrics and Evaluation. GBD India compare data
visualization. http://vizhub.healthdata.org/gbd-compare/india (accessed
Aug 1, 2018).