Medical research in India and the rise of non-communicable disease
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3371 (Published 29 June 2016) Cite this as: BMJ 2016;353:i3371
In India’s two tiered health system many have criticised the government for a lack of public spending on health. Public health expenditure marginally increased from 1.0% to 1.3% of gross domestic product (GDP) from 2009 to 2013.1 Over this period total health expenditure (including private expenditure) increased fractionally from 4.4% to 4.5% of GDP.2 Such low overall levels of spending, in a country ranked as the third largest economy in the world,3 are inadequate to deal with the vast inequalities and high levels of poverty.
The 2012 World Health Organization report No Health Without Research underpins the crucial but often overlooked part research has in the long term strengthening of health systems, improving the equitable distribution of high quality health services, and advancing human development.4 Economic and social development have done much to improve health in India. But the country’s success in reducing its burden of communicable disease over the past few decades is largely down to the establishment of large national institutions, investment in research and innovation, and successful interventions in public health.5
Health research has many benefits. As well as the potential to develop new diagnostic tools and treatments, it enables the appropriate planning of healthcare services, permits constant evaluation and improvement of medical care, and allows rigorous investigation of risk factors and disease associations.6 The importance of population based research is shown by the fact that modest reductions in major risk factors for cardiovascular disease in the United Kingdom have led to gains in life years four times higher than drug treatments provide.7 Implementation of research programmes also helps to retain talented physicians and scientists and promotes collaboration with the pharmaceutical and medical technology industries.
Investment in institutional research helps to build infrastructure in resource poor settings,6 providing widespread economic benefit in addition to improvements in health. Economists have found that medical research results in increased productivity, contributing greatly to the national economy.8 A lack of investment in research limits the long term ability of healthcare systems to robustly counteract future disease threats. The ongoing global explosion of antibiotic resistant infections shows the effect of a lack of investment in research and development of antibiotics as well as in surveillance, prevention, and control of infections.9
Changing burden of disease
Over the past few years India has seen a shift in its burden of disease, with a relatively large decrease in the burden of communicable disease and an increase in non-communicable diseases (NCDs). The global burden of disease study, published in 2015,10 found that from 1990 to 2013 the proportion of disability adjusted life years (DALYs) attributable to ischaemic heart disease more than doubled, currently making it the leading cause of disease burden in India. Over the same period the proportion of total DALY’s due to lower respiratory tract infections and tuberculosis (TB) decreased by 60% and 27% respectively. Iron deficiency anaemia was the leading cause of years lost to disability in 1990, but by 2013 it was overtaken by NCDs such as lower back pain and depressive disorders. Figure 1⇓ shows the top five causes of death in India in 1990 and 2013.10
Dietary risk, air pollution, and high blood pressure were the three leading risk factors for disease in 2013, ranked above risk factors for infectious disease such as unsafe water and lack of sanitation. It is projected that by 2050 the proportion of people aged 60 and above in India will grow almost threefold from 8.4% to 22.6%.12 Such a demographic shift will continue to increase the burden of NCDs such as stroke, cancer, and ischaemic heart disease. Reducing rates of NCDs has other benefits apart from health outcomes. For instance, a 2% annual reduction in NCD death rates is estimated to increase economic growth by 1% a year after a decade.13
If India is to successfully focus on preventing NCDs in the long term then the government must look to adequately support the development of institutes and national public health programmes dedicated to researching and preventing NCDs. This may require further investment in nationwide epidemiological studies investigating trends, causes, and risk factors of NCDs, or expanding existing clinical trials and investigations into novel diagnostics and treatments.
National research funding
Of the numerous bodies involved in medical research in India, the most prominent is the Indian Council of Medical Research (ICMR), under the purview of the Ministry of Health and Family Welfare (MHFW), which has ultimate control over the formulation, coordination, and promotion of biomedical research in India. The ministry also coordinates 13 national health programmes aiming to prevent and control disease, as well as collecting data for epidemiological, population based health research. The Ministry of Science and Technology also invests in health research, primarily through the Council of Scientific and Industrial Research, the Department of Biotechnology, and the Department of Science and Technology.
I analysed open access budgetary information for all 32 national research institutes associated with the ICMR,14 all 13 national public health programmes coordinated by the MHFW,15 and funding for the Department of Biotechnology16 for the years 2014-15. It was not possible to disentangle the budgetary allocation of Council of Scientific and Industrial Research and Department of Science and Technology, though the majority of their budgets (Rs33bn (£330m; €430m; $448m) and Rs25bn respectively17 18) is not spent on health related research.
Of the 32 national research institutes, 16 are classified as primarily focusing on communicable disease. Seven institutes are dedicated to NCDs, three to basic sciences, three to reproductive health, and three to nutrition. Data were inaccessible for four of the smaller institutes: the Centre for Advanced Research in Nutrition, Centre for Advanced Research in Neonatal Health, Bhopal Memorial Hospital and Research Centre, and Desert Medicine Research Centre. Of the 13 national programmes, six are for communicable disease and seven for NCDs.
I separated the budgets for each institute or programme into disease domains to determine the distribution of funding. Analysing each domain of research separately has limitations since there are likely to be areas of overlap between different projects. However, comparisons have been made according to the institute or programme’s description of its primary function. Although national public health programmes in India involve more than research, such financial data are important to include in the analysis because the programmes provide vast opportunities for research.
Research produced as a result of these nationwide programmes has resulted in significant progress in combating many health problems, including tuberculosis19 and iodine deficiency.20 The development of such initiatives reflects the translation of research into policy. In order to ascertain which areas of health are truly being prioritised in India, it is essential to look at money given to each national programme.
Where the money is spent
The overall calculated budgetary data included both internal and external funding. The majority (Rs40.4bn) of the research budget was dedicated to communicable disease, with just Rs7bn for NCDs, Rs5bn to biotechnology and basic science, and Rs780m to other health research.
Table 1⇓ shows the breakdown of funding between individual institutes and programmes within the communicable disease domain. The national programmes received most investment, with the National AIDS Control Programme getting 44% of funding and the National Tuberculosis Control Programme getting 17.6%. The two institutes with the most funding were the National Institute for Research in Tuberculosis and the Institute of Medical Statistics, both of which received about 1% of overall funding for communicable disease.
Distribution of finances for communicable disease
Table 2⇓ shows the breakdown of funding for NCDs. Similar to communicable disease, most of the money went to national programmes, with the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke getting 41.1% of overall investment. Of the ICMR institutes, the National Institute of Occupational Health got the most funding and the National Institute of Environmental Health the least.
Distribution of finances for non-communicable disease
Biotechnology and basic sciences received 12.4% of the overall research funds (table 3⇓), with most of the money going to biotechnology projects. The remaining 2% of health funding goes to ICMR institutes whose work covers both communicable and non-communicable diseases.
Distribution of finances for biotechnology/basic sciences and other research areas
Focus must shift
The focus on communicable disease research is to some extent warranted in a country that has been struggling with infectious disease for decades. But the increase in prevalence of lifestyle related risk factors demands a more proportional response in national research expenditure. NCDs were estimated to account for 53% of all deaths and 44% of disability adjusted life years (DALYs) lost in 2005.21 Projections indicate a further increase to 67% of total deaths by 2030. Yet my analysis shows that just 13.2% of the total funding was earmarked for NCD research. The cost of treating NCDs is almost double that for other illnesses,22 and research is urgently required to help expand existing national databases, monitor disease levels, and develop more cost effective strategies to combat these diseases.
The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke received 41% of all NCD funding. This seems appropriate since cardiovascular disease is the major contributor to the NCD burden in India, causing 52% of NCD associated deaths and 29% of total deaths,23 24 and India’s cancer burden is predicted to nearly double in the next 20 years, from slightly over a million new cases in 2012 to more than 1.7 million by 2035.25 However, this programme receives much less than those for communicable disease: Rs2.9bn compared with Rs17.9 and Rs7.1bn for the National AIDS Control Programme and National TB Control Programme respectively.
Environmental health is also neglected. The National Institute of Research in Environmental Health, which was established in 2010, got just 0.34% of the total budget for NCDs and 4.6% of the total ICMR budget for research institutes. In 2004, environmental factors, including pollution and water sanitation, were estimated to account for 24% of the total disease burden in India.26 Analysis of routinely collected air quality data indicates that annual average concentrations of small particulate matter (PM10) are critically high at more than half of the 503 locations monitored across India,27 and Delhi has been declared the most polluted city in the world.28
In 2007, China, which is at a similar stage of economic development to India, issued its first National Environment and Health Action Plan.29 The plan established surveillance networks for environment and health, with national surveys to determine the effect of pollution on health. By contrast, India’s National Action Plan on Climate Change, announced in 2008,30 did not focus on health but included enhanced public healthcare services and assessment of diseases attributable to climate change. There was no robust strategy for enhancing vital environmental health research in India. Given the long term implications of the environment on both communicable and non-communicable disease, this area requires more political attention and funding.
Investment in research has helped India to tackle the problems of communicable disease. The effect of these is now decreasing, and similar investment is required to prepare it for future problems with non-communicable disease.
Key messages
India needs to develop convergent health policies that address both communicable and non-communicable disease
Research and public health efforts have been largely responsible for the reduction in prevalence of many communicable diseases
The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke receives only 11% of the funding given to programmes for AIDS and tuberculosis
A coordinated national effort to monitor, evaluate, and counteract the effect of the environment on health is also needed
Footnotes
Contributors and sources: VJ has a masters degree in public health and expertise in health policy. The analysis is based on open access data from Indian government websites.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare
Provenance and peer review: Not commissioned; externally peer reviewed.