- Life expectancy rises but 6 out of 10 deaths now due to non-communicable diseases
- Under-5 mortality rate is improving nationwide, but there is a four-fold difference between states
- Even in states of similar development levels, there are major differences in the burden of leading diseases, highlighting vast health inequalities
- The rate of premature death and disability for ischaemic heart disease is 9 times higher in some states compared to others; and 6 times higher for stroke
- Overall burden of tuberculosis in India is highest in the world and its rate varies 9-fold between states
- Child and maternal malnutrition still leading risk factor for premature death and poor health, and is highest in the poorer states of north India
- Air pollution, diet, and obesity an increasing threat to health across many states
Today (14 Nov), The Lancet publishes the first comprehensive analysis of the health of India's 1.34 billion citizens--encompassing almost a fifth of the world's population. The analysis aims to equip the government with evidence to identify specific state-level health challenges and priorities for intervention. This massive effort brings together over 200 leading health scientists and policy makers from more than 100 institutions across India as part of the India State-level Disease Burden Initiative .
For the first time, the study estimates the key drivers of ill health, disability, and premature death in all 29 states, many of which have populations the size of large countries, and include people from over 2000 different ethnic groups. It analyses 333 diseases and injuries and 84 risk factor trends for each state in India between 1990 and 2016 as part of the Global Burden of Disease 2016 study.
The researchers divided India's states into four groups according to their level of development or epidemiological transition, using the ratio of illness and premature death caused by communicable, maternal, neonatal, and nutritional diseases (CMNNDs) versus non-communicable diseases (NCDs) and injuries as an indicator.
"Individual states in India are in different phases of epidemiological transition, and this has resulted in wide inequalities in the magnitude and progress against various diseases and their causes", explains Professor Lalit Dandona, Public Health Foundation of India, Gurugram, India, who led the study. "This has major policy implications for national and local governments. Rather than taking a more generic approach, these new estimates will be crucial to steering health policy to take account of specific health problems and risks in each state, and ultimately achieving the government's vision of assuring health for all." 
Significant improvements in health, but major inequalities between states
The Indian population has gained nearly a decade of life expectancy since 1990, rising to 66.9 years in men and 70.3 years in women. But there are wide inequalities between states, with life expectancy for women ranging from 66.8 years in Uttar Pradesh to 78.7 years in Kerala.
Since 1990, India has made substantial gains in health, with the overall health loss from all diseases and conditions about one-third less per person in 2016 than in 1990. But progress has been mixed, with greater improvements in states at the most advanced phases of development (eg, Kerala and Goa), compared to those in the earlier stages (eg, Assam, Uttar Pradesh and several other poorer north Indian states).
Child health remains a particular concern, with high levels of neonatal and under-5 disease relative to other age groups (figure 5). The under-5 mortality rate has reduced substantially since 1990 in all states, but rates in Assam (52 deaths per 1000 livebirths) and Uttar Pradesh (48 deaths) are four times higher than in Kerala (13 deaths), indicating major health inequalities.
Slow progress in reducing infectious, maternal, neonatal, and nutritional diseases in many states
By 2003, the total burden of ill health, as measured by DALYs, had shifted from CMNNDs to a dominance of disabling NCDs and injuries. But the extent of this dominance varies widely between states--with about half of the total disease burden due to NCDs in Bihar, Jharkhand, Uttar Pradesh, and Rajasthan, and around three-quarters in Kerala, Goa, and Tamil Nadu.
Overall, the burden from CMNNDs has decreased. Yet, diseases that primarily cause illness and death in children and mothers continue to dominate in the country. Lower respiratory infections and diarrhoeal diseases were the 3rd and 4th leading causes of health loss in 2016, accounting for about 9% of all premature death and ill health (figure 3).
Moreover, there are wide differences between states in terms of overall progress. For instance, Jharkhand has rates of death and illness due to diarrhoeal disease 9 times higher than Goa, while Rajasthan has rates due to lower respiratory infections 7 times higher than Kerala (figure 4).
Despite signs of progress, several CMNNDs including diarrhoeal diseases, iron-deficiency anaemia, and tuberculosis still cause a disproportionate amount of ill health, and claim more lives, than is expected for India's stage of development, particularly in states in the early stages of epidemiological transition. For example: the rate of premature death and illness from iron-deficiency has not improved since 1990, still causing 3.5% of the total disease burden in 2016; has a disease burden that varies more than 3-fold between the states; and is 3 times higher than expected based on India's level of development.
NCDs a major cause of disease burden like never before
As a result of urbanisation and ageing, the burden of NCDs is large and rapidly rising in all states. The fastest-growing causes of ill-health over the last 26 years were diabetes (increased by 174%) and ischaemic heart disease (up 104%). Ischaemic heart disease (responsible for 8.7% of the disease burden in 2016) and chronic obstructive pulmonary disease (COPD; 4.8%) were the leading causes of premature death and ill health in 2016, overtaking lower respiratory infections and diarrhoeal diseases. More than 60% of deaths (6.1 million) in India in 2016 were due to NCDs, up from about 38% in 1990.
Even states in similar levels of development showed striking differences in the burden of death and illness from some leading NCDs. For instance, Punjab has much higher rates of premature death and ill health due to diabetes and ischaemic heart disease, but lower rates due to COPD compared to neighbouring Himachal Pradesh, despite the two states both being at an advanced level of epidemiological transition. Similarly, Uttar Pradesh has much higher rates due to COPD, but lower rates from stroke compared to Madhya Pradesh, despite both states being at a similarly early stage of epidemiological transition (figure 4).
Rapid urbanisation is responsible for rising deaths and health loss from road injuries in most states since 1990, highlighting the lack of a comprehensive national policy for injury prevention. The burden of road injures was highest in Jammu and Kashmir, with rates of premature death and illness three times higher than in Meghalaya; the burden of self-harm was highest in Tripura, with rates six times higher than in Nagaland (figure 4).
The authors warn that a bigger and more organised effort, supported by better financial and human resources, is needed to control the growing burden of NCDs.
Child and maternal malnutrition still leading risk factor, whilst diet, obesity, and air pollution an increasing threat
Despite decades of investment in prevention and treatment programmes, child and maternal nutrition remains the leading risk factor for poor health in India, responsible for 15% of all ill health and premature death in 2016, whilst unsafe water, sanitation, and handwashing accounted for 5% (figure 8).
The burden of malnutrition remains three times higher among states in the earlier stages of development (eg, Bihar and Rajasthan) compared to the most advanced (eg, Goa and Kerala). The authors warn that these 'unacceptably high risks' should be key priorities for health improvement in India, with a focus on behavioural change alongside provision of better nutrition and safe water and sanitation.
Other highly preventable risks such as poor diet (eg, diets high in salt and low in vegetables and fruit), high blood pressure, high cholesterol, and high body mass index are contributing to the growing burden of NCDs. Together they accounted for almost a quarter of poor health in 2016--over two times more than in 1990. Worryingly, the burden of these risks has increased in every state since 1990, with generally higher rates in states in more advanced stages of epidemiological transition (eg, Punjab and Tamil Nadu; figure 7).
One area that needs special attention is exposure to air pollution which is among the highest in the world. In particular, the exposure to ambient outdoor air pollution has increased by around 17% since 1990. Ambient outdoor and household air pollution together are responsible for almost 10% of the total disease burden in 2016, highlighting the need to increase the use of cleaner technologies to reduce air pollution from various sources. The burden is highest in the northern states, with Rajasthan, Uttar Pradesh, and Bihar having levels of premature death and ill health due to air pollution around three times higher than Kerala and Goa (figure 7).
The researchers say that the risk factors included in the report only explain about half of the disease burden in India, emphasising the need for understanding the additional broader determinants of health such as income and education.
According to Professor Dandona: "India has come a long way. But these individual state estimates reveal major health inequalities between the 'nations' within this nation. Over the past two decades the Government of India has launched many initiatives and programmes to address a variety of diseases and risk factors. However, these data show that what we have being doing up to now is not enough. With the availability of state-specific findings now identifying the diseases and risk factors that need most attention in each state, we can act more effectively to improve health in every state of the country. This has the potential of reducing the major health inequalities observed currently between the states, and this would also help achieve better health outcomes for India as a whole." 
Finally, the authors note that the cause of death data in India should be improved, and the data gaps for some risk factors and diseases across the states should be addressed, in order to have even better estimates in future. They call for the development of a comprehensive health information system to improve data collection and quality in many states.
A Lancet Editorial, published alongside the study, notes: "Encouragingly, a flourishing era of innovation in the way health care is being designed and delivered is being invested in and led by the states themselves. For example, Kerala, Tamil Nadu, and the Punjab are strengthening health systems in pilot projects for UHC. However, these state level actions should not diminish the responsibility of the federal government for increasing public investment in health care. We are disappointed by the lack of ambition of President Modi's Government to invest only 2.5% of its GDP into health care by 2025, when the global average for countries is about 6%. The rise in India's economic fortunes and its aspiration to progress to the same level as its neighbour, China, is something of an embarrassment, given how improvements to health trail so far behind. Until the federal government in India takes health as seriously as many other nations do, India will not fulfil either its national or global potential."
NOTES TO EDITORS:
This study was funded by the Bill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India; and the World Bank.
 The India State-level Disease Burden Initiative is a collaboration between the Indian Council of Medical Research, Public Health Foundation of India, Institute for Health Metrics and Evaluation at the University of Washington, and experts and stakeholders from 100 institutions across India.
 Quotes direct from author and cannot be found in text of Article.
These estimates are being presented to the Government of India and the state governments on Tuesday 14 November, 2017.
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