Global Health Magazine | Article

Global Health Magazine Article: India: The Private Sector Takes Action on NCDs
India: The Private Sector Takes Action on NCDsBy: Muruga Vadivale and Aparna Thomas

India is the second most populous nation in the world with nearly 1.2 billion inhabitants. The impact of chronic and infectious diseases on patients, families and society is significant. In addition to the obvious effects on quality of life, morbidity and mortality, the burden of these diseases to the country’s economy is substantial in terms of loss of productivity, loss of employment, and health care expenditures.

The scope and impact of non-communicable diseases (NCDs) such as cardiovascular disease, cancer and diabetes are so complex that all stakeholders, including governments, NGOs, academia and the private sector need to participate in developing solutions. The common challenge – and opportunity – for all stakeholders is to save millions of people from premature death and debilitating health complications, as well as promoting social and economic development.

Health care in India has shown remarkable improvement since independence in 1947. However, in 2004, out of the estimated 10.3 millions deaths, 1.1 million (11 percent) were due to injuries, 4 million (39 percent) to communicable diseases and 5.2 million (50 percent) to NCDs.

In 2005, 9.2 million years of productive life were lost in India due to heart diseases, stroke and diabetes. This translated into US$ 9 billion of lost national income. The projected 2005-2015 cumulative loss of national income for India due to these premature deaths is US$ 237 billion.

India’s total health care spending was 4.2 percent of gross domestic product (GDP) in 2008-09. Public spending on health (0.93 percent of the GDP) was among the lowest in the world, and the reason for private expenditures accounting for 78 percent of total health spending in the country.

Although India’s economy is witnessing remarkable growth, inadequate health care infrastructure continues to be a barrier to access to basic health services. For example, there are only 60 physicians per 100,000 people as compared to 140 per 100,000 globally. Likewise, India has only 130 nurses per 100,000 people whereas the global average is 280 per 100,000.

It is estimated that more than 46 percent of patients travel more than 100kms from small towns to urban facilities to seek proper medical care. Knowing that 71 percent of the population is living in rural areas, accessibility to health care infrastructure is a major issue.

Therefore, in cooperation with other stakeholders (such as doctors, hospitals, institutes and policy makers), Sanofi India is organizing a number of actions to understand the real burden of disease, raise awareness of diabetes and increase access to health care in rural areas.

Estimating the prevalence and risk factors of diabetes and hypertension
The International Diabetes Federation estimates that India has the second highest prevalence of diabetes in the world with 50.8 millions diabetes patients in 2010.
Indians with hypertension are projected to number 214 million in 2025, up nearly 100 million since 2000. Hypertension is an important worldwide public-health challenge because of its high frequency and concomitant risks of cardiovascular and kidney disease.
Reliable information about the prevalence of hypertension and diabetes is essential to the development of health policies for prevention and control of these conditions.

Therefore, in January 2009 Sanofi launched SITE (Screening India’s Twin Epidemic), a cross-sectional study to estimate the prevalence of diagnosed and undiagnosed cases of diabetes and hypertension in outpatient settings in major cities across India.

As of July 2011, SITE has enrolled 15,662 patients from 802 centers across eight states in India (Maharashtra, Delhi, West Bengal, Tamil Nadu, Andhra Pradesh, Karnataka, Gujarat, and Madhya Pradesh) and has partnered with 800 general practitioners and consulting physicians to conduct the screenings, record and report the results. The study was conducted in waves over two years, one state at a time, with 2,000 patients screened from each state over two days per wave.

“Through SITE we hope to identify gaps in treatment needs at the first point of contact for a patient,” said Dr. Shashank Joshi, a consultant endocrinologist at the Lilavati Hospital and the national coordinator of the study. “SITE will give us important insights on how we screen patients for risk factors and how well we manage them versus current guidelines.”

The results obtained in the different cities are progressively communicated at congresses. When the results of the New Delhi screenings were announced, medical researchers, public health officials and physicians were able to compare the prevalence of diabetes and hypertension in Maharashtra and New Delhi. The findings were both alarming and revealing:

■The twin epidemics of diabetes and hypertensions do exist in both states, although more serious in Maharashtra where 29 percent of the patients were both diabetic and hypertensive, as compared to 21 percent in New Delhi.
■Hypertension is more prevalent than diabetes in both states.
■Less expected, were the regional differences: both diabetes and hypertension are more prevalent in Maharashtra (40 percent and 56 percent, respectively) than in New Delhi (33 percent and 48 percent, respectively).
■As troubling were the rates of patients who had been diagnosed and treated, but whose conditions were still uncontrolled.
■In Maharashtra, three-quarters of known diabetics had uncontrolled blood sugars (Hba1c levels), as compared to two-thirds in New Delhi.
■Uncontrolled hypertension was also a serious problem in both states and occurred at about the same rate: 79 percent in Maharashtra and 77 percent in New Delhi.
Through partnerships with doctors, hospitals and other organizations in these eight States, SITE has already started to raise disease awareness of the risk factors, symptoms and treatment of diabetes, hypertension and other related conditions, such as cardiovascular diseases.

Celebrating Diabetes Control
According to Dr. Shailesh Ayyangar, general manager of Sanofi in India and vice president of Sanofi in South Asia, “The diabetes epidemic makes it essential to create awareness about diabetes control. The ‘I Am A Champ’ program will help patients who are in control to reach out to others with their inspiring testimonials. Treatment regimens must be complemented by a more comprehensive approach to diabetes management for the health and well-being of a patient.”

Through the program patients and caregivers are learning that a positive attitude and few lifestyle changes to support their treatment regime can empower them to improve their health and well-being.

India’s first ever Diabetes Awards Ceremony was the first step to kick start the ‘I Am A Champ’ program which is based on the model of peer-to-peer counselling. Champions from various regions in the country were assessed on various parameters such as their understanding of diabetes, awareness about diabetes complications, their fitness and diet regime, and the ‘champ’ factor. In their role as ‘Champions of Diabetes’, they will be the face and voice of this awareness program in their respective cities.

Sanofi provides the 42 (seven national and 35 regional) ‘champs’ with platforms to share their testimonials, create awareness amongst other diabetes patients in their respective cities and address their concerns on managing the disease. These individuals symbolize triumph over diabetes and are a beacon of hope for countless other diabetics who often believe that ‘life is over’ once they are diagnosed with diabetes.

Empowering Doctors in Rural India
Prayas, meaning endeavour in Sanskrit, focuses on empowering doctors in rural India with the latest developments and updates in medicine.

The government is doing extensive work through the National Rural Health Mission (NHRM) to provide effective health care to India’s rural population. Considering the magnitude of the task, NHRM has incorporated public-private partnerships in its strategic roadmap for achieving its public health goals. This was echoed by Shomita Biswas, joint secretary, Public Health, Government of Maharashtra, citing,“Two major problems that government is facing at the grass root level is lack of infrastructure and adequately trained human resources. There is also an acute need of training institutes for developing nursing and paramedic professionals at the rural level. These are some of the areas where government will look forward to getting support from the private organizations.”

Launched in 2009,Prayas is aimed at bridging the diagnosis-treatment gap through a structured continuing education program for rural doctors across India. In Prayas, specialists from semi-urban areas share latest medical knowledge, clinical experience and practical insights through structured workshops for general practitioners- from smaller towns and villages in the interiors of India - through a ‘mentor-mentee’ model.



As of July 2011, 4,700 workshops have been conducted across 14 states for more than 11,500 rural doctors. Forty-eight expert doctors and 574 mentors have so far lent their support to Prayas. The workshops cover major acute-care therapy areas like respiratory diseases, infections, allergies, gastrointestinal disorders, etc. Each course is validated and certified by reputable international medical associations such as the American College of Physicians and the American Gastroenterology Association, amongst others.

Progressively disease awareness camps were organized to improve awareness and treatment seeking behaviour of patients in these regions. These camps focus on topics like child health, anaemia and malnutrition, and diarrhea which are in line with the needs of the patients.

With plans to cover new doctors under the program on a continual basis, there should be 100,000 mentees by 2015.

To complement this knowledge-based program, the Hoechst Business Unit, a Sanofi Unit has also launched a new range of quality medicines at affordable prices in these geographical areas. The product range helps address the challenges of accessibility, affordability and availability of quality medicines to patients in remote villages. In addition, a new distribution model with emphasis on availability of drugs to the most rural interiors is being established. The next step is to adapt this model to the fight against diabetes which is also developing in rural areas.

References
1. World Health Organization, Global Health Observatory. Accessed July 17, 2011
2. World Health Organization, Global Infobase. Accessed July 17, 2011
3. World Health Organization, Chronic Disease Report, 2005. Accessed July 17, 2011
4. World Health Organization, Global Health Expenditure Database. Accessed July 26, 2011
5. World Health Organization, World Health Statistics 2010. Accessed July 17, 2011
6. Accessible Healthcare - Joining the Dots Now. White paper, TECHNOPAK Leadership Forum on Healthcare, Oct. 20, 2011, New Delhi.
7. International Diabetes Federation. 4th Atlas - 2009. Accessed July 17, 2011
8. Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet 2005;365: 217-23.
9. Joshi S.R. et al. SITE 1st wave results (Maharashtra). ADA June 2010. Mithal A. et al. results from Delhi (abstract 2496-PO) and Jindal S. et al. Results from Madhya Pradesh (abstract 2497-PO). ADA June 2011.
10. Marketing Whitebook (2011-12) report.



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Dr. Muruga Vadivale is senior director, Medical and Regulatory Affairs, Sanofi India. Aparna Thomas is senior director, Communications and Public Affairs, Sanofi India.