Number crunching

From diarrhoea in Bihar to diabetes in Kerala: New data shows major diseases in each Indian state

A new study lays the ground for specific policies and investment based on its findings.

The nature of disease in India has changed dramatically over the past three decades. Communicable diseases like diarrhoea, measles, tuberculosis and lower respiratory infections were the dominant causes of illness in the 1990s but these have now been surpassed by non-communicable diseases like heart disease and chronic obstructive pulmonary disorders that are more widespread in recent years.

However, this epidemiological transition has not been uniform across India largely because of big differences in the status of social development among its 1.34 billion people from 2,000 different ethnic groups. Therefore, states in India are at different stages of epidemiological transition. More developed states with better social indicators are at an advanced stage of transition, which means that they have less illness caused by infection and malnutrition but are dealing with higher burdens of non-communicable diseases. Less developed states are still battling the old problems like infections, anaemia and neonatal disorders. However, even among states with similar levels of development, there are striking differences in the burden of death and illness from major non-communicable diseases.

A new study by researchers from the Indian Council for Medical Research, the Public Health Foundation of India and the Institute for Health Metrics and Evaluation in the United States published in The Lancet and released on Tuesday estimates disease burdens and risk factors for disease in each state in India. The metrics used in the study are deaths, disability-adjusted life-years or DALYs, prevalence, incidence, and life expectancy for 333 disease conditions and injuries and for 84 risk factors.

Health is a state subject. Two-third of public spending on health across the country is made by individual states governments and one-third by the union government. State-specific disease data may help direct investment and frame specific policies to tackle the major diseases in each state, say the authors of the study.

“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,” said Professor Lalit Dandona from the Public Health Foundation of India in a statement accompanying the release of the study.

The study shows that chronic diseases are now not only linked to better socio-economic standing. Conditions like heart disease and pulmonary disease are widely prevalent even among the poor and are linked to poverty. Meanwhile, even some advanced states have diseases of under development.

The study details the leading causes of disease and disability in India. Ischemic heart disease, which is heart disease caused by narrowing of blood vessels and thus restricting blood flow, is the major cause of illness followed by chronic obstructive pulmonary disorders, which is a group of non-communicable lung diseases characterised by poor air inflow and long-term breathing problems that get progressively worse. Diarrhoea and lower respiratory infections follow in third and fourth place.

DALYs: Disability-adjusted life-years is a measure of overall health expressed as the number of years lost due to ill-health, disability or early death.
DALYs: Disability-adjusted life-years is a measure of overall health expressed as the number of years lost due to ill-health, disability or early death.

So, what are the major diseases in each state of India?

Kerala is at the most advanced stage of epidemiological transition. The most common cause of illness here is ischemic heart disease. Other major causes of DALYs – an overall disease burden expressed as the number of years lost due to ill-health, disability or early death – are sense organ disorders like vision and hearing impairments, followed by diabetes and then lower back and neck pain.

Like Kerala, Himachal Pradesh, Punjab, Tamil Nadu and Goa have higher incidences of non-communicable lifestyle diseases than communicable, maternal, neonatal and nutritional diseases.

But there are some differences even among these states. For instance, Punjab has much higher rates of premature death and ill health due to diabetes and ischemic heart disease, but lower rates due to chronic obstructive pulmonary disease compared to neighbouring Himachal Pradesh.

In sharp contrast to states in an advanced stage of epidemiological transition is Bihar, the state which is at the earliest stage of epidemiological transition. Diarrhoeal diseases are the biggest causes of DALYs in Bihar. Lower respiratory infections are also a major cause of illness. However, Bihar also has a high rate of ischemic heart disease and chronic obstructive pulmonary disorders.

Diarrhoeal disease is the leading cause of illness in Jharkhand, Uttar Pradesh and Odisha, other states where epidemiological transition has been slow.

The leading risk factor for disease and death in India in 2016 was child and maternal undernutrition, which is largely a result of poverty. Bihar, Jharkhand, Uttar Pradesh, Rajasthan, Assam, Chhattisgarh and Madhya Pradesh, all states with lowest epidemiological transition levels, have the highest rate of disability caused by child and maternal undernutrition.

Not surprisingly, the second biggest risk factor is air pollution.

Half of all premature deaths caused by air pollution in the world occur in India. Air pollution contributes to India’s disease burden from cardiovascular disease, chronic respiratory disease, and lower respiratory infections. The disease burden due to air pollution is highest in states like Rajasthan, Uttar Pradesh, and Bihar. With air pollution from emissions and dust from the power, industrial, transport, and construction sectors projected to grow, it is likely to contribute to more disease across states in coming years.

“India needs an effective, coordinated response that immediately reduces the level of air pollution at it sources – crop burning, vehicles powered by internal combustion engines, coal fired power plants, among others,” said Michael Klag, dean of the Johns Hopkins Bloomberg School of Public Health and member Independent Advisory Committee for the Global Burden of Disease. “It is time to put regional differences and concerns within India aside and make choices to benefit everyone in India, especially children.”

Greater urbanisation will also pose a major challenge to Indian health systems in coming years, say the authors of the study. India is beset with ever increasing unplanned urbanisation and half of the population projected to be urban by 2050, up from a third at present.

A third challenge is an ageing Indian population. Increasing life expectancy will lead to more disability and a larger disease burden.

“Trying to deal with diseases and conditions that contribute to huge societal burdens of disease by treatment alone is like trying to keep a leaky boat afloat by bailing it out with a bucket,” said Klag. “In addition to treating disease, that is, bailing out the boat, one also has to stop up the leaks so water doesn’t come in – prevent the occurrence of new disease. Also, treatment is seldom perfect. It is seldom totally effective, except for certain infectious diseases, and has side effects. Prevention means that disease never occurs.”

With input from Mahim Pratap Singh.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

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Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

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Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.