Malnutrition Archives - InnoHEALTH magazine

Urban Health in India: Present and Future

InnoHEALTH magazine digital team — Mon, 31 Oct 2022 11:13:20 +0000

Maj. Gen. (Prof.) Atul Kotwal is currently serving as Executive Director, National Health Systems Resource Centre (NHSRC), an apex body for technical assistance under NHM, MoHFW, GoI. With more than 37 years of experience, Dr. Kotwal is a medical professional, public health researcher, administrator, educator, mentor, and teacher with significant contribution to the field of Public Health. He has diverse experience including serving in the armed forces, as a Public Health Advisor in Botswana, Africa and providing technical support to GoI in the erstwhile Planning Commission.

His areas of expertise include health systems, policy and planning, primary healthcare, urban health, health technology, epidemiology, implementation and inter-disciplinary research. Dr. Kotwal has received numerous awards for his contribution to the Armed Forces, Sena Medal (Gallantry) and Vishisht Sewa Medal (VSM), being the notable ones. With more than 140 publications in indexed journals, his contribution to research, evidence generation, knowledge sharing and providing academic support in the field of public health is invaluable.

India too is urbanizing rapidly, in alignment with the global trend. As per the Census of India, the population in urban areas has increased from 286.1 million in 2001 to 377.1 million in 2011 (projected 483 million, in 2022).

Urbanization is one of the leading global demographic trends with a significant impact on the health and well-being of the population. As per World Health Organisation (WHO), more than 55% of the world’s population lives in urban areas, which is likely to increase to 68% by 2050. This scenario puts great demand on governments across the globe to address the varied vulnerabilities and issues affecting the health issues and health outcomes of urban populations. As most of the urban population growth will occur in developing countries, their governments have a unique opportunity to plan and guide urban development in a way that favourably affects the health and well-being of the urban population.

India too is urbanizing rapidly, in alignment with the global trend. As per the Census of India, the population in urban areas has increased from 286.1 million in 2001 to 377.1 million in 2011 (projected 483 million, in 2022). The urban population constitutes 31% of the total population in India and is expected to increase to more than 550 million by 2030.

The unprecedented growth of this scale comes with issues such as disparities, inadequate urban housing and infrastructure, overcrowding, insufficient urban amenities, etc. An increasing number of communicable and non-communicable diseases, malnutrition among children, insufficient water and sanitation facilities, etc., affect the health status of the urban population. According to the National Family Health Survey (NFHS 5), 18.5 percent of the urban population does not have access to an improved sanitation facility, and 1.4 percent do not have access to an improved drinking water source.

The private sector undoubtedly makes significant contributions to fill the existing gaps in healthcare service provision; however, several issues plague the efficiency, equity and quality of their services.

Urban Health: Existing Policies and Programmes in India

India’s focus on the comprehensive development of the urban health system is a recent phenomenon. The Tenth Plan observed that “Unlike the rural health services, there have been no efforts to provide well-planned and organized primary, secondary and tertiary care services in geographically delineated urban areas. As a result, in many areas, primary health facilities are not available; some of the existing institutions are underutilized, while there is overcrowding in most of the secondary and tertiary centres”. Responding to this reality, the National Urban Health Mission (NUHM) was launched in 2013 under the overarching umbrella of the National Health Mission (NHM).

The launch of NUHM was a decisive step taken by the Government of India, acknowledging the heterogeneous nature of communities in urban areas, which resulted in unique vulnerabilities and requirements and initiated systematic development of urban health systems across the country. NUHM provides a comprehensive framework for setting up urban health systems in different contexts and defines institutional mechanisms at the national, state, and district levels for implementation.

Under the National Urban Health Mission, every municipal corporation and town panchayat becomes a unit of health planning. The Mission provides flexibility to states/UTs to choose the model which suits the needs and capacities of states to best address the healthcare needs of the urban population, especially the urban poor. The broad framework of programme implementation proposes rationalizing the available human resources, improving access through communitised risk pooling mechanisms, and enhancing participation of community in planning and management of the health care service delivery by ensuring a community link volunteer such as ASHA (Accredited Social Health Activist) or Link Worker from other programs like ICDS, etc.

Empowerment of the community through awareness generation, whereby they can demand services from the Health System, is also an important area of emphasis under the NUHM. Urban health systems have an edge over their rural counterparts in the availability of human resources for health, as the urban density of doctors is nearly four times that in rural areas and three times higher in the case of nurses. However, the outcome of NUHM has not been uniform across urban areas in the country.

Although, the out-of-pocket expenditure (OOPE) as a percent of Total Health Expenditure has reduced from 64.2% in 2013-14 to 48.2% in 2018-19, the average OOPE in government hospitals in urban areas is Rs. 326, while it is Rs. 1082 in private facilities. There also exist wide variations in OOPE across states in the country. The Government of India is implementing programmes such as the Free Drugs and Diagnostics initiative, PM-National Dialysis programme, etc., in rural and urban areas with the aim to reduce OOPE endured by families; However, It is imperative also to understand the context-specific direct and indirect costs which people in urban areas might have to spend like transportation to the health facility, loss of wages, etc., to understand the true extent of the financial burden endured while accessing healthcare services.

The role of private healthcare providers in provisioning healthcare services in urban areas is another critical aspect which requires more focus. The private sector healthcare providers in urban areas consist of individual practitioners or small nursing homes that provide services focusing on curative care, in addition to medium-sized hospitals and large hospital chains targeting tertiary care. The private sector undoubtedly makes significant contributions to fill the existing gaps in healthcare service provision; however, several issues plague the efficiency, equity and quality of their services.

These include distributional inequalities of private providers in urban areas, a lack of uniform standards and protocols to which the private practitioners may adhere to, a need for quality assurance and cost control mechanisms for private providers, lack of implementation of the Clinical Establishment Act (CEA) in some states, leading to a regulatory vacuum, etc.

Although the 74^th Amendment of the Constitution places the healthcare system under local governance, its role in delivering healthcare in many states is almost negligible. In states like Kerala, decentralization under NUHM has resulted in the devolution of functions, funds, and functionaries to the ward level; some states in India have not reached this stage. Research shows that the weak capacity of ULBs is one of the major reasons for their sub-optimal involvement in planning and implementing health policies and programs.

It is in this context that the Government of India launched the Ayushman Bharat – Health and Wellness Centres (HWCs) in 2018, marking the shift of focus from selective to comprehensive primary healthcare. Under this program, the Government of India targets the conversion of 1.5 lakhs SHCs, PHCs, and UPHCs into Health and Wellness Centres by December 2022. Funds for converting UPHCs into UPHC-HWCs are also provided under recently launched schemes like Ayushman Bharat – Prime Minister’s Health Infrastructure Mission (PM-ABHIM) and the 15^th Finance Commission earmarked grants for local bodies.

Universal Comprehensive Primary Health Care is planned to be provided through these Urban Health and Wellness Centres (Urban HWCs) and Polyclinics, in addition to dedicated funds for diagnostics in close collaboration with Urban Local Bodies. Another critical intervention is establishing cost-effective laboratory systems at the district level that provide rapid, reliable, and accurate test results, with defined upwards and downwards linkages.

These facilities will enable decentralized delivery of health care services closer to people, thereby increasing the reach of the public health system to the vulnerable and marginalized in urban areas. The Government of India is building the capacity of rural and urban local bodies to plan and implement the urban components envisaged under PM-ABHIM and the 15^th Finance Commission grants. This can bring revolutionary improvements in the governance of urban and rural health systems.

A ‘one size fits all’ approach will not work for urban areas, as the requirements of residents residing in the same slum area may vary as they migrate to slums from different contexts and cultures.

Way Forward:

Moving forward, the most crucial strategy to improve health outcomes in urban areas is understanding the dynamic and complex nature of health vulnerabilities experienced by the urban population. A ‘one size fits all’ approach will not work for urban areas, as the requirements of residents residing in the same slum area may vary as they migrate to slums from different contexts and cultures. In order to respond suitably and adequately to improve health outcomes, there is a need for a granular understanding of the vulnerable groups and the nature of their vulnerability. This strategy will pay huge dividends in improving the health of urban communities and will improve social inclusion.

Strengthening communities’ involvement in the governance of urban health systems also requires enhanced focus. Community platforms like Mahila Arogya Samitis (MAS) in urban areas bring community members into the governance process through their participation in regular monitoring of health care services. This empowers communities to take ownership and hold the health system accountable for their needs.

Strengthening convergence and collaboration between different departments in urban areas is another aspect that needs improvement. Implementation of vertical programs without integration into the existing health system results in duplication of efforts and resources and poses a sustainability issue.

The ‘Framework of Implementation for NUHM’ emphasizes that the focus of the Mission is on the urban poor, which includes residents of listed and unlisted slums and vulnerable populations such as the homeless, rag-pickers, street children, rickshaw pullers, construction and brick and lime kiln workers, sex workers, and other temporary migrants. However, considering the efforts made by the government to ensure quality, affordability and availability of healthcare services in urban areas, it is time to move from the current targeted approach to a holistic approach. Additionally, following a targeted approach in the provision of services is not easy, given the dynamic and temporary nature of populations in urban areas.

With the exponential growth of the urban population, it is only rational to anticipate a parallel increase in the urban poor population in the coming years. The above mentioned approaches are not exhaustive; however, these could be used as a starting point in devising strategies. Effective knowledge-based health planning, implementation, monitoring, evaluation, and health governance are required at all levels to ensure equitable access, affordability, and quality of services provided at urban health facilities and to ensure equitable health outcomes in the dynamic and complex urban populations.

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Social Behavior Modification for Unmet Need of Prevention

InnoHEALTH Magazine — Fri, 01 Nov 2019 06:45:48 +0000

Resource poor communities are unable to afford expensive, supply side solutions for deficiencies in healthcare. Lack of finances, medical manpower, drugs and technology renders poor communities vulnerable to diseases, many of which are either preventable or curable. Unmet needs of preventive care often turn a completely preventable disease into a condition requiring expensive secondary or tertiary care, which further burdens the alreadymeagre resources.

The solution may lie in improving the demand side of the healthcare. Modifying social health behaviour may be the least expensive method to reduce disease burden in a community. Save a Mother (SAM), a healthcare NGO, works on the demand side by embedding in the communities to carry prevention to the doorstep. SAM has developed an Effective Social Persuasion platform (SAM-ESP), a model forsocial behaviour change, which reduces disease burden. In the past 11 years, SAM has successfully replicated the solution in different locations in India.

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Established in 2008, SAM has focussed on five themes: maternal and infant mortality reduction, population stabilization, TB control and malnutrition. SAM has worked with vulnerable communities of 3 million people living in 1800 villages and one urban slum, located in 10 districts of 4 states of India. SAM has shown considerable success in all the programs at all locations. SAM is currently active in five districts.

SAM selects the target population on the following criteria:
Targeting vulnerability: SAM works with the poor and vulnerable communities who lack education, income, assets, status and access to healthcare.
Targeting pregnant, infants and children: SAM follows all pregnant women, infants and children under 5 years in the community.
Targeting reproductive age: For population stabilisation, SAM targets reproductive age group women and married couples between ages 18 and 49 years and adolescent girls from 10 to 19 years.
Targeting disease: SAM targets the families and contacts all TB patients, malnourished children and high-risk pregnant women.
SAM-ESP Innovation: SAM has developed a cost-effective platform for changing health behaviour ofa community. Health activists, in partnership with local public and private healthcare stakeholders, convert awareness to actionable knowledge. SAM has successfully used its Effective Social Persuasion Platform (SAM-ESP) in multiple locations. ESP relies on seven assumptions.
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Behaviour modification is the least expensive way to reduce disease burden.

Health is an individual and community responsibility; ownership of this responsibility empowers a community to demand healthcare rights. A campaign to push health information may improve awareness but is not sufficient by itself. Awareness is just one of many steps to change behaviour. Other essential steps include: a sustained, intensive, repetitive campaign without a predefined end time-point, encouraging peer to peer nudge and a methodical transfer of ownership to the community leaders.

Messages scripted by the community encourages their ownership. Trained volunteer activists can lead and sustain the ESP without external help.

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An established SAM-ESP platform can be used to address multiplehealth problems. SAM-ESP is not yetanother awareness building program. Awareness is often assumed to be equal to behaviour change. In practice, it is not true. Communication programs and prevalent awareness programs merely touch the surface without translating into significant behaviour change. SAM-ESP is a multi-step process, where awareness in just one of many steps for a sustainable behaviour change.

SAM promotes community ownership of both health and healthcare. SAM believes, that health is an individual and community responsibility and getting healthcare, as a right, has to be learned. SAM-ESP is a peoples’ program, which ensures that the health system is responsive and accountable.

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SAM trains volunteer health activists who lead the program and develops a cadre of social entrepreneurs, who sell contraceptives, sanitary pads and nutritional products. SAM field workers are from the community where they live and work. They are available 24/7 and take health to the doorstep of the recipients. The program sets no predetermined end date; repetitive training continues till SAM meets the objectives.

The following steps describe its execution:

Organize, create structure and build leadership capacity: SAM has well-trained field staff and managers;the voluntary directors of the organization are professionals from healthcare and management. Each district has a manager, trainers, and supervisors who are selected from the local population. They receive intensive training not only in health issues but also in motivational techniques, training methods and leadership.

Develop messages: SAM believes that a good message should be simple without technical jargon, short with less than five points, easy to understand without explanation and emotionally connected with a local need. For better retention, a message could be in the form of a story, song or a slogan. Some messages should be created by the community to feel ownership.

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Train health activists: Master trainers train volunteer health activists to be responsible for village health issues. Training is repetitive and intense.

Teach people: SAM organizes the village into a healthcare community. Field supervisors motivate and mobilize villagers and discuss each topic of healthcare with a specific training module. SAM uses local community resources to create training material and health leaders script their own songs and slogans. Activists meet villagers repeatedly to discuss best practices. Repetitive training of health activists and villagers is essential.

Cooperation with public and private health systems: SAM establishes linkage with the local private and public health system. Utilizing all available public health resources is an essential component of the program. Public health workers are invited to all meetings. This linkage creates awareness, which improves demand of healthcare and encourages accountability.

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Evaluation and improvement: Programs are monitored by community involvement and by participatory research action. Results lead tocourse correction.
Replicate: Solutions are validated and replicated in other locations.

Measuring impact: Each program starts with a baseline and finishes with an end-line evaluation. SAM defines objectives, activities, outputs and outcomes before the start of the program. They measure monthly progress against all these parameters.

Process of measuring impact is a four-step process:
Data Collection at community level: The field workers collect data during house visits and community meetings. They upload it on a smartphone.
Data review at block level: Field officers collate and review data every month at a block level. They validate it through client interaction.

Data validation at district level: SAM validates data through a monitor and evaluation protocol which includes field visits, focus groups and comparison with public health data. SAM compares outcomes and impact with similar programs run by the government and other private organisations.

External agency evaluation: Periodically, SAM engages external agencies to evaluate its work. The funding partners also send external evaluators to check the progress and impact.

Direct impact: Since inception, SAM has trained 37,000 volunteer health activists who live in the villages and are available to the community. SAM has directly impacted over 1,150,000 million people through maternal, child health, population stabilisation and TB control programs.

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Through maternal, child health and population stabilization programs, SAM has directly impacted: 530,000 women and over approximately 100,000 infants. SAM follows all (100%) pregnant women in the villages and has reduced maternal mortality by 90% and infant mortality by 60%. In some places, SAM has done even better. In the past 6 years, in 167 villages of Gadag, Karnataka; maternal mortality rate has decreased to 15.8 from 364 and the Infant mortality rate has decreased to 5 from 46.

Through population stabilizations program, the marriage of girls under 18 years of age has decreased to almost zero. Contraceptive use has increased from 28% to 62% and supplychain management has reduced the unmet need for contraception from 10.8 % to 2% been running in 700 villages. 287,042 people have participated in 14,552 community meetings. 13,973 people have had sputum tested. Sputum was positive for TB in 1329 people and 14 had multiple drug resistant TB. All received supervised treatment. SAM has directly helped with education and surveillance of 130,000 contacts of TB patients and helped another 317,000 community members with awareness program. TB detection rate has improved 3.7 times.

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Indirect impact: SAM estimates that approximately 0.9 to 1 million people, who did not actively participate in its programs, became aware of the benefits from those who attended our programs.

Women feel empowered, which has opened their minds to many choices in life. They express their opinions freely. Men and elderly women, who were suspicious and objected to their women attending public meetings, have mellowed their resistance and have even become enablers. Girls attend school more regularly and the number of girls attending college has increased. Adolescents participation has increased. Public health system and their workers are more responsive to public demand.Local elected politicians are responsive.

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Discussion: Multiple theories have attempted to explain the health behaviour of individuals. The most popular is the Health Belief Model (HBM), which was developed about 40 years back. It postulates that people make healthcare decisions based on perceived susceptibility to disease and consequences. The response is tempered by perceived benefits of action and with a belief that benefits outweigh risks. While this theory, like other theories, builds a plausible reference point to explain behaviour, it gives no guidance for modification of individual behaviour.

Theory of Planned Behaviour suggests that a person should be empowered with ability (self-efficacy) to change behaviour. The person should believe that the behaviour will improve his health and is socially approved. It has also been recommended that principles of marketing could be applied to a social cause, where the product to be sold is behaviour change.

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SAM model comes close to a hybrid variety of HBM, building self-efficacy and social marketing. SAM tries todevelop social efficacy through the agency of health activists by using techniques similar to social marketing. SAM Effective Social Persuasion is a people’s platform, which needs further elucidation and expansion. SAM is looking to use entertainment education or gamification for behaviour modification and use of technology in early detection of noncommunicable diseases. SAM seeks collaboration with others for mutual learning, sharing resources and scaling-up the program in vulnerable population.

About the author

Dr. Shiban Ganju is the Chairman of Atrimed Pharmaceuticals and Founder of Save A Mother Foundation, USA. He has dedicated his life to healthcare. Dr. Ganju graduated from AIIMS New Delhi and received advanced training in Internal Medicine and Gastroenterology both in India and USA. He is a consultant specializing in gastroenterology, liver disease and nutrition in hospitals in the greater Chicago area. His commitment to and understanding of how to drive improvements in health outcomes has benefitted big strata of society.

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Specific health situation of Indian states

InnoHEALTH Magazine — Thu, 03 May 2018 09:14:37 +0000

Importance of understanding the specific health situation of each state

Understanding the health and disease trends in groups of states at a similar level of development or epidemiological transition is an important intermediate step in teasing apart the heterogeneity of disease and risk factor epidemiology in India. However, effective action to improve health must finally be based on the specific health situation of each state. This point is elucidated by significant variations in the burden from leading diseases and risk factors in 2016 between the following pairs of states that have physical proximity and are at similar levels of development and epidemiological transition.

The major EAG states of Madhya Pradesh and Uttar Pradesh both have a relatively lower level of development indicators and are at a similar less advanced epidemiological transition stage. However, Uttar Pradesh had 50% higher disease burden per person from chronic obstructive pulmonary disease, 54% higher burden from tuberculosis, and 30% higher burden from diarrheal diseases, whereas Madhya Pradesh had 76% higher disease burden per person from stroke.

The cardiovascular risks were generally higher in Madhya Pradesh, and the unsafe water and sanitation risk was relatively higher in Uttar Pradesh. The two North-East India states of Manipur and Tripura are both at a lower-middle stage of epidemiological transition but have quite different disease burden rates from specific leading diseases.

Tripura had 49% higher per person burden from ischaemic heart disease, 52% higher from stroke, 64% higher from chronic obstructive pulmonary disease, 159% higher from iron-deficiency anaemia, 59% higher from lower respiratory infections, and 56% higher from neonatal disorders.

Manipur, on the other hand, had 88% higher per person burden from tuberculosis and 38% higher from road injuries. Regarding the level of risks, child and maternal malnutrition, air pollution, and several of the cardiovascular risks were higher in Tripura.

The two adjoining north Indian states of Himachal Pradesh and Punjab both have a relatively higher level of development indicators and are at a similar more advanced epidemiological transition stage. However, there were striking differences between them in the level of burden from specific leading diseases.

Punjab had 157% higher per person burden from diabetes, 134% higher burden from ischaemic heart disease, 49% higher burden from stroke, and 56% higher burden from road injuries.

On the other hand, Himachal Pradesh had 63% higher per person burden from chronic obstructive pulmonary disease. Consistent with these findings, Punjab had substantially higher levels of cardiovascular risks than Himachal Pradesh.

The Executive summary says these examples highlight why it is necessary to understand the specific disease burden trends in each state, over and above the useful broad insights provided by trends common for groups of states at similar levels of epidemiological transition, if health action has to be planned for the specific context of each state.

The chances of achieving the overall health targets set by India would be much higher if the biggest health problems and risks in each state are tackled on priority than with a more generic approach that does not take into account the specific disease burden trends in each state.

Application of the state-level disease burden findings and future work. The findings in this report of the India State-level Disease Burden Initiative can be used for planning of state health budgets, prioritisation of interventions relevant to each state, informing the government’s Health Assurance Mission in each state, monitoring of health-related Sustainable Development Goals targets in each state, assessing impact of large-scale interventions based on time trends of disease burden, and forecasting population health under various scenarios in each state.

Future plans of the India State-level Disease Burden Initiative include annual updates of the estimates based on newly available data, and more disaggregated findings such as the rural-urban estimates planned for next year and sub-state level estimates subsequently when adequate data become available.

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Lifestyle diseases: A threat to backward states

InnoHEALTH Magazine — Wed, 02 May 2018 08:13:02 +0000

Lifestyle diseases like chronic respiratory and heart diseases are killing more people in India than communicable ailments like Tuberculosis (TB) or Diarrhea in every states, including most backward belts, says the India State-Level Disease Burden Initiative’s Report.

Among the leading non-communicable diseases, the largest disease burden or Disability-Adjusted Life Year (DALY) rate increase from the period of 1990 to 2016 was observed for diabetes at 80 per cent, and ischaemic heart disease at 34 per cent.

In 2016, three of the five leading individual causes of disease burden in India were non-communicable, 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 fourfold for diabetes across the country.

The key metric used in the study is DALYs, which is the sum of the number of years of life lost due to premature death and a weighted measure of the years lived with disability due to a disease or injury. The use of DALYs to track disease burden is recommended by India’s National Health Policy of 2017.

While ischaemic heart disease and diabetes generally had higher DALY rates in states that are at a more advanced epidemiological transition stage toward non-communicable diseases, the DALY rates of chronic obstructive pulmonary disease were generally higher in the Empowered Action Group (EAG) states that are at a relatively less advanced epidemiological transition stage.

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The report shows that communicable diseases constitute almost two-thirds of the disease burden in India from a little over a third in 1990. Despite the transition, which is associated with development, malnutrition remains the single top risk for health loss.

All states have thus made what’s called the ‘epidemiological transition’ there remain wide variations in their disease profiles with some having made that transition as early as 1986, and others as recently as 2010.

The first group to make the transition in 1986 included Kerala, Tamil Nadu, Goa, Himachal Pradesh and Punjab. The last group to do so, accounting for the highest number of people (588 million), made the transition almost a quarter of a century later, in 2010. This group included Bihar, Uttar Pradesh, Madhya Pradesh, Chhattisgarh, Jharkhand, Rajasthan and Odisha. India as a country made the transition in 2003.

The Report’s executive summary says with almost one-fifth of the world’s population living in India, the health status and the drivers of health loss are expected to vary between different parts of the country and between the states.

Accordingly, effective efforts to improve population health in each state require systematic knowledge of the local health status and trends. While state-level trends for some important health indicators have been available in India, a comprehensive assessment of the diseases causing the most premature deaths and disability in each state, the risk factors responsible for this burden, and their time trends have not been available in a single standardised framework.

The Report finds that the Health status improving, but major inequalities between states 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.

There were, however, continuing inequalities between states, with a range of 66.8 years in Uttar Pradesh to 78.7 years in Kerala for females, and from 63.6 years in Assam to 73.8 years in Kerala for males in 2016.

The per person disease burden measured as DALYs rate dropped by 36% from 1990 to 2016 in India, after adjusting for the changes in the population age structure during this period. But there was an almost two-fold difference in this disease burden rate between the states in 2016, with Assam, Uttar Pradesh, and Chhattisgarh having the highest rates, and Kerala and Goa the lowest rates.

While the disease burden rate in India has improved since 1990, it was 72% higher per person than in Sri Lanka or China in 2016. 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 with the lowest in Kerala in 2016, highlighting the vast health inequalities between the states.

Large differences between states in the changing disease profile of the total disease burden in India measured as DALYs, 61% was due to communicable, maternal, neonatal, and nutritional diseases (termed infectious and associated diseases in this summary for simplicity) in 1990, which dropped to 33% in 2016. There was a corresponding increase in the contribution of non-communicable diseases from 30% of the total disease burden in 1990 to 55% in 2016, and of injuries 18 %.

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Global nutrition needs swift efforts

InnoHEALTH Magazine — Mon, 30 Apr 2018 11:05:15 +0000

Global nutrition crisis threatens human development, demands ‘critical step change’ in response – Report

Women’s health in India has emerged as a major nutritional challenge with the country wrestling largest number of anemic women in the world and the other having to tackle diseases related with obesity –that is on the rise, warns the latest Global Nutrition Report, 2017. It says there is malnutrition among adults globally.A total of 614 million women aged between 15–49 years were affected by anemia. India had the largest number of women impacted, followed by China, Pakistan, Nigeria and Indonesia.In India and Pakistan, more than half of all women of reproductive age have anemia.

It is a global issue that many women in high-income countries also suffer from; prevalence rates may be as high as 18% in countries such as France and Switzerland. Obesity (body mass index (BMI) ≥30) is most common among North American men (33%) and women (34%), and lowest among Asian and African men (6%) and Asian women (9%).

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Overweight and obesity are increasing in almost every country and are a real concern for many low and middle income countries, not just high-income ones.The problem affects more women than men in all the world’s regions, reflecting a wider global gender disparity.

Hypertension is most common (28%) among African women and European men, and lowest (11%) among North American women. A quarter of Asian and Latin American men suffered from raised blood pressure in 2015. While more women worldwide are affected by obesity, the case for diabetes and hypertension is mixed. There is more diabetes among men than women in Asia, Europe, Northern America and Oceania, and more hypertension among men than women in all regions except Africa.

The world now faces a serious nutrition- related challenge, whether stemming from under nutrition or obesity, states Global Nutrition Report 2017.

The report found the vast majority (88%) of countries studied face a serious burden of two or three of these forms of malnutrition. It highlights the damaging impact this burden is having on broader global development efforts.

“The world can’t afford not to act on nutrition or we risk putting the brakes on human development as a whole,” said Corinna Hawkes, Co-Chair of the Global Nutrition Report’s Independent Expert Group and Director of the Centre for Food Policy at City, University London. “We will not achieve any of the Global Goals for Sustainable Development (SDGs) by the 2030 deadline unless there is a critical step change in our response to malnutrition in all its forms. Equally, we need action throughout the goals to tackle the many causes of malnutrition.”

The Report calls for nutrition to be placed at the heart of efforts to end poverty, fight disease, raise educational standards and tackle climate change.

“We know that a well-nourished child is one-third more likely to escape poverty,” said Jessica Fanzo, Bloomberg Distinguished Professor of Global Food and Agriculture Policy Ethics at Johns Hopkins University and Global Nutrition Report CoChair.

At least 41 million children under five are overweight, with the problem affecting high and lower income countries alike
At least 10 million children in Africa are now classified as overweight
One-third of North American men (33%) and women (34%) are obese
155 million under-fives are stunted; Africa is the only region where absolute numbers are rising, due to population growth
52 million children worldwide are defined as wasted, meaning they do not weigh enough for their height

In all 140 countries studied, the report found ‘significant burdens’ of three important forms of malnutrition used as an indicator of broader trends:
1) childhood stunting-children too short for their age due to lack of nutrients, suffering irreversible damage to brain capacity,
2) anemia in women of reproductive age-a serious condition that can have long term health impacts for mother and child, and
3) overweight adult women-a rising concern as women are disproportionately affected by the global obesity epidemic.

“They will learn better in school, be healthier and grow into productive contributors to their economies. Good nutrition provides the brainpower, the ‘grey matter infrastructure’ to build the economies of the future.”

Rates of undernutrition in children are decreasing, the report said, with recent gains in some countries. But global progress is not fast enough to meet internationally agreed nutrition goals, including the Sustainable Development Goals (SDG) target 2.2 to end all forms of malnutrition by 2030.

EmornUdomkesmalee, Co-Chair of the Global Nutrition Report’s Independent Expert Group and Senior Advisor, Institute of Nutrition, Mahidol University, Thailand, said, “It’s not just about more money – although that is important – it’s also about breaking down silos and addressing malnutrition in a more joined-up way alongside all the other drivers of development. There’s a powerful multiplier effect here that we have to harness.”

The report found that overweight and obesity are on the rise in almost every country.With 2 billion of the world’s 7 billion people are now overweight or obese and a less than 1 per cent chance of meeting the global target of halting the rise in obesity and diabetes by 2025.

Rising rates of anemiaamong women of reproductive age are also cited as a concern with almost one in three women affected worldwide and no country on track to meet global targets. “Historically, maternal anemia and child undernutrition have been separate problems to obesity and noncommunicable diseases,” said MsFanzo. “The reality is they are intimately connected and driven by inequalities everywhere in the world. That’s why governments and their partners need to tackle them holistically, not as distinct problems.” Donor funding for nutrition rose by just two per cent in 2015, to US$867 million, representing a slight fall in the overall percentage of global aid. The report says funding needs to be ‘turbo charged’ and calls for a tripling of global investments in nutrition, to $70bn for over next 10 years to tackle childhood stunting, wasting and anemia and to increase breastfeeding rates. Crucially, donors are only spending 0.01 per cent of official development assistance on diet related Non-Communicable Diseases, a ‘disturbingly low’ level.

Pledges to invest in nutrition must be ‘concrete’ and ‘acted upon’, not ‘empty rhetoric’, the report said. Of the 203 commitments made at the Nutrition for Growth Summit in 2013 those most likely to be classified as ‘on course’ are the UN agencies’ at 86 per cent, followed by ‘other organisations’ at 75 per cent and NGO policy commitments at 73 per cent.

The report found there is a critical need for better data on nutrition – many countries don’t have enough data to track the nutrition targets they signed up to and to identify who is being left behind.

Report says the world consumes too much salt. Intake varies by region, but no region had intakes within the WHO-recommended limits of 2 g/day of sodium. Asia has the highest intake (4.3 g/day of sodium), followed by Europe (4.0 g/day of sodium). At national level, only seven countries (Burundi, Comoros, Gabon, Jamaica, Kenya, Malawi and Rwanda) have sodium intakes within desirable limit).

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