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Insights into Editorial: A toolkit to think local

Insights into Editorial: A toolkit to think local



The ‘India State Level Disease Burden’ report, prepared as part of the Global Burden of Disease (GBD) Study 2016, and published in Lancet, has found that every State in India has a higher burden from non-communicable diseases and injuries than from infectious diseases. The study used multiple data sources to map State-level disease burden from 333 disease conditions and injuries, and 83 risk factors for each State from 1990 to 2016. It was released by Vice-President. 

The estimates are based on analysis of all identifiable epidemiological data from India over 25 years. The report, which provides the first comprehensive set of state-level disease burden data, risk factors estimates, and trends for each state in India, is expected to inform health planning with a view toward reducing health inequalities among States.

What is GBD and why is it important?

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is the single largest and most detailed scientific effort ever conducted to quantify levels and trends in health. Led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, it is truly a global effort, with over 1,000 researchers from more than 100 countries, including 26 low- and middle-income countries, participating in the most recent update.

GBD creates a unique platform to compare the magnitude of diseases, injuries, and risk factors across age groups, sexes, countries, regions, and time.

For decision-makers, health sector leaders, researchers, and informed citizens, the GBD approach provides an opportunity to compare their countries’ health progress to that of other countries, and to understand the leading causes of health loss that could potentially be avoided, like high blood pressure, smoking, and household air pollution.

IHME provides GBD results in visualization tools, allowing people to interact with the vast amounts of data and the trends they identify. These unique tools are beneficial when trying to identify specific information for age groups, sexes, causes, risks, and comparison to other regions.

India State-Level Disease Burden Initiative:

In order to improve health programs and planning in India, The Institute for Health Metrics and Evaluation (IHME) is partnering with the Indian Council of Medical Research (ICMR) and the Public Health Foundation of India (PHFI) – in collaboration with the Ministry of Health and Family Welfare, Government of India – to generate subnational disease burden and risk factor estimates.

Need of this initiative:

Over the past 25 years, India has seen a major epidemiological transition.

  • The burden of premature death and health loss from non-communicable diseases such as heart disease, stroke, diabetes, chronic obstructive pulmonary disease, and road traffic injuries has increased substantially, while the burden due to lower respiratory infections, tuberculosis, diarrhea, and neonatal disorders remains high.
  • With over 1.2 billion people in its 29 states, India’s disease burden due to these major conditions is expected to vary significantly by geography and across different population groups.
  • Because national estimates do not provide enough detail for targeted action, reliable subnational estimation of disease burden in India will allow policymakers to make more informed decisions to improve population health.

Policymakers in India need reliable disease burden data at subnational levels. Planning based on local trends can improve the health of populations more effectively.

To address this crucial knowledge gap, a team of over 250 scientists and others from around 100 institutions who are part of the India State-Level Disease Burden Initiative has analysed and described these trends for every State from 1990 to 2016.

With support from the World Bank and the Bill & Melinda Gates Foundation, IHME, ICMR, and PHFI will work together over the next few years to provide a disease burden analysis, by age and gender, over time, for hundreds of diseases, injuries, and risk factors for each of India’s states. 

Basis of the study

The findings of the study are based on analysis of data from all available sources.

  • This includes vital registration, the sample registration system, large-scale national household surveys, other population-level surveys and cohort studies, disease surveillance data, disease programme data, administrative records of health services, disease registries, among others.
  • The key metric used to assess burden is disability-adjusted life years (DALY), 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 an injury.
  • This allows comparisons of health loss between diseases, risk factors, States, sexes, age groups, and over time.

Inequalities among States

The per person disease burden, measured as DALY rate, has dropped in India by 36% from 1990 to 2016, but there are major inequalities among States with the per-person DALY rate varying almost twofold between them.

  • The burden of most infectious and childhood diseases has fallen, but the extent of this varies substantially across India.
  • Diarrhoeal diseases, lower respiratory infections, iron-deficiency anaemia, neonatal disorders, and tuberculosis still continue to be major public health problems in many poorer northern States.
  • The contribution of most major non-communicable disease categories to the total disease burdenhas increased in all States since 1990. These include cardiovascular diseases, diabetes, chronic respiratory diseases, mental health and neurological disorders, musculoskeletal disorders, cancers, and chronic kidney disease.
  • The contribution of injuries — the leading ones being road injuries, suicides, and falls — to the total disease burdenhas also increased in most States since 1990.

The continuing high burden of infectious and childhood diseases in poorer States along with the rising tide of non-communicable diseases and injuries poses a particularly ominous challenge for these States.

Substantial increases in health spending by the government and expansion of suitable preventive and curative health services are necessary to prevent this potentially explosive situation.

Major differences are also observed for individual diseases between neighbouring States that are at similar levels of development. This points to the need for State-specific health planning instead of generic planning.

The leading risk factors

Disease burden can be reduced by addressing the risk factors for major diseases.

The findings of the study reveal that three types of risks – undernutritionair pollution, and a group of risks causing cardiovascular disease and diabetes – are akin to national emergencies as these have the potential to significantly blunt the rapid social and economic progress to which India aspires.

  1. Under Nutrition: It is remarkable that even though there is a declining trend in child and maternal under nutrition, this is still the single largest risk factor in India, responsible for 15% of the total disease burdenin 2016
  • Under nutrition increases the risk of neonatal disorders, nutritional deficiencies, diarrhoeal diseases, and lower respiratory and other common infections.
  • This burden is 12 times higher per person in India than in China.
  • While this risk factor is relatively worse in the major northern poor States and Assam, it is amazingly the leading risk in over three-fourths of the States across India.


  1. Air Pollution:  Air Pollution levels in India are among the highest in the world, making it the second leading risk factor in 2016, responsible for 10% of the total disease burdenin the country. 
  • Air pollutionincreases the risk of cardiovascular diseases, chronic respiratory diseases, respiratory infections, and cancer.
  • The burden of outdoor air pollutionhas increased in every part of India since 1990 because of pollutants from power production, industry, vehicles, construction, dust and waste burning. 
  • Air pollutionis higher in the northern States, but is considerable even in the southern States.

The unacceptably high disease burden due to undernutrition and air pollution in most of India must be brought to an end through systematic large-scale interventions with robust short- and long-term goals.


  • Non Communicable Diseases: A group of risks that include unhealthy diet, high blood pressure, high blood sugar, high cholesterol and overweight, which increase the risk of ischaemic heart disease, stroke and diabetes, contributed a tenth of the total disease burden in India in 1990, but increased to a quarter of the total burden in 2016.
  • While these risks are currently higher in the relatively more developed States, their phenomenal increase in every State over the past quarter of a century poses a grave threat.

Unless serious attempts are made soon to address this surge through massive up scaling of interventions in the health, food, agriculture, housing and urban development sectors, these risks can result in major deterioration in the health status across all States, rich and poor.

An important point to note related to undernutritionair pollution, and the risks causing cardiovascular disease and diabetes is that the interventions needed to address them have to involve extensive collaborations between the health sector and other relevant sectors.

Inputs for health planning

These findings reported by the India State-Level Disease Burden Initiative provide the most comprehensive mapping so far of the magnitude of diseases and risk factors in every State, their age and sex distributions, and trends over a quarter century — all in a single standardised framework.

  • This initiative will produce scientific papers, policy briefs, workshops, and seminars to encourage discourse and monitor changing disease trends. 
  • State-of-the-art GBD interactive visualization tools will be used to bring to life the initiative’s findings.
  • This will allow comparisons between states, which will be particularly useful for decision-makers in understanding trends in diseases and risk factors in order to plan further action. 
  • The findings of the India State-Level Disease Burden Initiativewill aid in decentralised health planning.

Way Forward

The effort was to produce an open-access, public good knowledge base, which has the potential of making fundamental and long-term contributions to improving health in every state of the country, through provision of the best possible composite trends of disease burden and risk factors for policy makers to utilise in their decision making.

The chances of achieving the overall health targets for India and of reducing health inequalities among States would be higher now if the biggest health problems and risks identified for each State are tackled on priority basis rather than with a more generic approach.

This new knowledge base and the annual updates planned by the India State-Level Disease Burden Initiative will provide important inputs for the data-driven and decentralised health planning and monitoring recommended by the National Health Policy 2017 and the NITI Aayog Action Agenda 2017-2020.