Poor water quality, a serious threat

By Y P Gupta
Of 1.42 million villages in India, 1,96,813 are affected by chemical contamination of water.
A recent United Nations report says that more than three million people in the world die of
water-related diseases due to contaminated water, which includes 1.2 million children. In India,
over one lakh people die of water-borne diseases annually. It is reported that groundwater in onethird of Indias 600 districts is not fit for drinking as the concentration of fluoride, iron, salinity
and arsenic exceeds the tolerance levels.
Rajasthan, Gujarat and Karnataka are the worst affected. About 65 million people have been
suffering from fluorosis, a crippling disease due to high amount of fluoride and five million are
suffering from arsenicosis in West Bengal due to high amount of arsenic.
According to an earlier UN agency report, since the worlds population has grown to over six
billion, many countries have been facing water crisis. A majority of the poor in these countries
do not have access to safe drinking water. Around 80 per cent of diseases in the developing
countries are attributed to poor quality of water supply.

The World Health Organisation reported that of the 10 million annual deaths in India, 7.8 lakh
are due to lack of basic health care amenities like effective sewage system, safe drinking water
supply, elementary sanitary facilities and hygienic conditions. Almost 90 per cent of diarrhoea
cases are due to contaminated water.
Getting worse
The UN reported that some 2.6 billion people in the world, mostly in Africa and Asia, do not
have access to basic sanitation, which increases the risk of diarrhoeal and other diseases fatal to
children. Also, rapid urbanisation, growth of unauthorised colonies, lack of amenities and
medical facilities and disposal of garbage have worsened the situation.
Water-borne diseases like cholera, gastroenteritis, diarrhoea have been erupting every year
during summer and rainy seasons in India due to poor quality of drinking water supply and
sanitation. A California think tank reported that as many as 76 million children could die
worldwide from water-borne diseases by 2020 if adequate safeguards are not taken.
Children among the poor are most vulnerable to water-borne infections as they are largely
undernourished and their immune systems are underdeveloped. Trans-Yamuna and resettlement
colonies of Delhi are largely afflicted every year from these diseases due to shortage of safe
drinking water.
A World Resources Report says: about 70 per cent of Indias water supply, is seriously polluted
with sewage effluents. The UN reported that Indias water quality is poor. It ranks 120th among
the 122 nations in terms of quality of water available to its citizens.
The World Development Report says: Delhis water supply is among the worst in many big
cities of the developing world. The Central Pollution Control Board has found that the tap water

in Delhi contains carcinogenic substances and the toxic quotient is five times higher than the
WHO standards. It is reported that of the 1.42 million villages in India, 1,96,813 villages are
affected by chemical contamination of water.
The water supply from rivers is invariably contaminated to a greater extent by bacteria, viruses
and parasites. These are found in large numbers in domestic sewage, effluent from slaughter
houses and animal processing plants, all of which contaminate water catchment areas.
Over 18,000 million litres of untreated sewage water enters the Yamuna river daily, passing
through Delhi, and thereby polluting it with toxic chemicals and high level of coliform and other
bacteria. The high level of coliform bacteria increases the incidence of water-borne diseases.
These microbes grow in the intestines of humans and animals, where they multiply and thereby
cause disease.
These water-borne pathogens survive under low temperature, low salinity and low intensity of
light. Warm temperature is favourable for their rapid growth. Also, industrial effluents and
municipal waste in Haryana have been polluting the western Yamuna canal water, and thereby
adversely affecting the drinking water supply in Delhi. A large number of fish deaths in recent
past in Punjab caused by industrial effluents created panic in certain areas of Punjab and
Rajasthan because the drinking water supply became unsafe.
It is reported that 10 per cent of diseases worldwide could be avoided by improving the water
supply, sanitation, hygiene and management of water resources. Today, water resources are
depleting due to increasing consumption because of rising population and improved living
standards in urban areas.
The government has committed to provide drinking water to all habitations by 2012 under the
millennium development goals and therefore has a major responsibility to provide safe drinking
water, particularly in urban slums and rural areas.

Availability of data for monitoring noncommunicable disease risk factors in India

Magdalena Z Raban a, Rakhi Dandona a & Lalit Dandona a
a. Public Health Foundation of India, ISID Campus, 4 Institutional Area, Vasant Kunj, New
Delhi, 110070, India.
Correspondence to Magdalena Z Raban (e-mail: [email protected]).
(Submitted: 26 May 2011 Revised version received: 17 August 2011 Accepted: 22 August
2011 Published online: 27 September 2011.)
Bulletin of the World Health Organization 2012;90:20-29. doi: 10.2471/BLT.11.091041

Introduction
Noncommunicable diseases (NCDs) were estimated to account for over 50% of the deaths
and 43% of the disability-adjusted life years (DALYs) lost in India in 20041and they are
prevalent across all socioeconomic strata in the country.2,3 According to predictions, by 2030
NCDs will account for almost three quarters of all deaths in India2 and the years of life lost
due to coronary heart disease will be greater in that country than in China, the Russian
Federation and the United States of America combined.2 To address the growing burden of
NCDs, the government of India has launched several programmes that aim to reduce the
prevalence of modifiable NCD risk factors.4,5 These risk factors, which include tobacco use,
alcohol use, low fruit and vegetable intake, physical inactivity, overweight and obesity, high
blood pressure, high blood glucose and high blood cholesterol, account for an estimated 61%
of cardiovascular disease deaths in low- and middle-income countries.6Information on the
prevalence of NCD risk factors in the population is crucial for NCD programme monitoring
and planning, and can assist in predicting the future burden of disease. Ideally, this
information should be collected periodically as part of NCD surveillance to allow
comparisons over time both nationally and at appropriate levels of disaggregation.
The STEPwise approach to surveillance (STEPS) of the World Health Organization (WHO),
based on conducting population surveys to collect information on the major modifiable NCD
risk factors, has been used in many studies globally7 and was designed for use in low- and
middle-income countries.8,9 In 2009, WHO proposed a set of core indicators derived from
STEPS for monitoring NCD risk factors nationally and globally. These core indicators were
deemed practical and easily obtainable by countries at all levels of technical capacity
(Box 1).10,11
Box 1. Core behavioural and biological noncommunicable disease (NCD) risk factor
indicators recommended by WHO for NCD monitoring10
Behavioural risk factors
Tobacco use

Prevalence of tobacco use use reported in three status categories: non-user, occasional user,
daily user.
Prevalence of cigarette smoking smoking reported in three status categories: non-smoker,
occasional smoker, daily smoker.
Alcohol use
Prevalence of alcohol consumption consumption reported in four status categories: lifetime
abstainer, past-12-month abstainer, drank in last 12 months but not current user, and current user
(defined as having drunk an alcoholic beverage in the past 30 days).
Prevalence of heavy episodic drinking (past week and past month) episodic drinking defined as
consumption of 5 drinks on a single occasion for men and of 4 drinks for women.
Diet
Prevalence of low fruit and vegetable consumption consumption defined as number of daily
servings of fruits and vegetables and reported in four groupings: 0; 12; 34; 5.
Physical inactivity

Total physical activity in adults reported in three categories: low level (insufficiently active) (<
600 METa-minutes per week); moderate level (minimally active) ( 600 but < 3000 METminutes per week); high level (sufficiently active) ( 3000 MET-minutes per week).
Biological risk factors

Body mass indexb (height and weight measurements)

Blood pressure
Fasting blood glucose
Blood cholesterol
a
Metabolic equivalent of task, a unit used to express the intensity of physical activity.
b
Weight in kilograms divided by height in metres squared (kg/m2).
In the light of the rising burden of NCDs and of government efforts to control NCDs in India,
NCD risk factor surveillance should be a priority for the national health information system.
To assess the current status of NCD risk factor information in India, we studied the
availability of data measuring the WHO core indicators and the STEPS indicators from
household surveys conducted in India over the 10-year period from 2000 to 2009.
Methods
Survey selection criteria
Household surveys that collected information on at least one risk factor in the general adult
population included in the WHO-recommended core indicators and STEPS indicators
(tobacco use, alcohol use, physical inactivity, diet, body mass index [BMI], waist and/or hip
circumference, blood pressure, fasting blood glucose, blood cholesterol),8 with data
collection completed in or after the year 2000 and with a minimum sample size of 5000
individuals, were included. This sample size would allow measurement of a risk factor with a
prevalence of 15% and a 2% absolute margin of error in males and females at the 95%
confidence level, taking into account survey design effect and response rate.8
Identification of household surveys
A previous study on the health information system in India identified household surveys that
form part of the countrys routine health information system.12 The web sites of the
organizations conducting these surveys were searched for additional, more recent household
surveys. The WHO Global NCD Infobase database was also searched.13 These initial
searches were followed by a PubMed search conducted in October 2010. The search strategy
is shown in Box 2.
Box 2. PubMed search strategy
The following keywords were searched in combination with India and epidemiology OR
prevalence OR distribution for articles published in the year 2000 or onwards:
tobacco, alcohol intake, fruit intake, vegetable intake, physical activity, exercise,
sedentary lifestyle, BMI, overweight, obesity, waist circumference, waist hip ratio,
blood pressure, hypertension, metabolic syndrome, diabetes, blood sugar,
hyperglycaemia, dysglycaemia, glucose abnormalities, cholesterol, lipids, coronary
heart disease, myocardial infarction, angina, heart, coronary, cardiovascular,
ischaemic heart disease, stroke; excluding publication type review.

Titles of the citations returned in the search were assessed and those clearly not relevant were
excluded. Abstracts of the remaining citations were reviewed, and full papers were reviewed
to identify those that potentially fulfilled the inclusion criteria. Multiple publications arising
from a particular survey were treated as a single survey. References cited in the full papers
were hand searched for other potentially relevant surveys.
Documentation from surveys
For each identified survey we recorded the year(s) it was conducted, the states covered,
sample size, age and sex included and rural/urban location. Surveys were ranked in
decreasing order of coverage and in terms of geographic representativeness as follows:
national, representative of states or regions: the sample covered the majority of the country
and was designed to be disaggregated to the state or regional level; national, nationally
representative only: the sample covered the majority of the country and was not designed to
be disaggregated to the state or regional levels; multiple-state, representative: the sample was
representative of the populations of more than one state; multiple-state, non-representative:
the sample covered multiple states but was not representative of their populations; singlestate, representative: the sample was representative of the population of one state; and singlestate, non-representative: the sample was not representative of the population of the state
covered. We also recorded whether the survey was periodic (i.e. whether earlier rounds had
been conducted or not). A survey conducted once with planned future rounds did not qualify
as periodic.
Behavioural and biological risk factors
We tried to access the survey questionnaires, either through web searches or by contacting the
study investigators, to identify the WHO-recommended core and STEPS behavioural risk
factor indicators measured. An indicator measured by the questionnaire was considered to be
the same as the WHO-recommended core or STEPS indicator if it met the indicator
definition, regardless of the questions used. To record the indicators measured by surveys
whose questionnaires were unavailable, we accessed the survey publications and used the
indicator definitions in the surveys, if described, or the indicators reported in them. For the
STEPS behavioural risk factor indicators, if a given indicator was not measured by a survey,
we examined the questionnaire or indicator definitions to determine and record if: (i) the
definition differed from that used by STEPS, or (ii) was not covered at all by the survey. We
obtained the WHO-recommended core and STEPS biological risk factors measured by each
survey from the relevant sections of the survey report, usually the methods section, or from
the questionnaire, if available. We entered all information on the behavioural and biological
risk factors measured by surveys into Microsoft Access 2007 (Redmond, United States of
America).
The surveys measuring WHO-recommended core and/or STEPS indicators were examined
according to their representativeness and periodicity. For WHO-recommended core
behavioural risk factor indicators, we recorded which surveys measured the indicators for a
particular risk factor completely or incompletely. A particular risk factor was considered to be
incompletely measured if not all indicators for that risk factor or not all indicator categories
were measured in a survey. For each STEPS behavioural indicator, we recorded any missed
opportunity for measurement. We considered that an opportunity to measure a given STEPS
indicator had been missed in either of the following situations: (i) for an indicator measured
by at least one survey, an opportunity to measure the indicator was missed whenever another,
more broadly representative survey failed to measure it because its definition differed from

the one used by STEPS; (ii) for an indicator not measured by any survey, an opportunity to
measure the indicator was missed whenever any survey failed to measure it because the
indicators definition differed from the one used by STEPS. Since large surveillance surveys
in India have been conducted roughly every five years, findings between two five-year
blocks, namely 20002004 and 20052009, were compared.
Results
The search strategy results are shown in Fig. 1. We identified 26 surveys 16 for 20002004
and 10 for 20052009 (Table 1).1439 Of these surveys, seven (26.9%) covered only rural or
urban populations or only males. Two (7.7%) were national and representative of states or
regions; two (7.7%) were nationally representative only; seven (26.9%) were multiple-state,
representative surveys; eight (30.8%) were multiple-state, non-representative surveys; one
(3.8%) was a single-state, representative survey, and six (23.1%) were single-state nonrepresentative surveys. Six surveys (24.0%) were periodic. Survey questionnaires were
available overall for 16 (61.5%) surveys. Indicator definitions were given in the published
reports of seven of the 10 surveys (38.5%) whose questionnaire was not available.
Fig. 1. Results of search strategy to identify surveys collecting information on
noncommunicable disease risk factors in India from 2000 onwards

Table 1. Household surveys collecting information on noncommunicable disease risk factors

in India that met inclusion criteria for study
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Behavioural risk factors

Table 2 shows the national and multiple state surveys that completely measured the WHOrecommended core behavioural risk factor indicators for at least one risk factor. National
surveys measured only the WHO-recommended core tobacco use indicators completely in
20052009; they did not measure any of the other risk factor core indicators completely
during either five-year period. WHO-recommended core indicators for alcohol use were not
measured completely by any survey, including single-state surveys, during 20002009. The
other risk factors had their core indicators measured completely in at least one survey during
20002004 and 20052009. The representativeness of the surveys measuring the core
indicators was somewhat better in 20052009 than in 20002004.
Table 2. National and multiple state surveys in India that completely or incompletely
measured core behavioural and biological noncommunicable disease risk factor indicators
recommended by the World Health Organization
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A substantial number of surveys measured the WHO-recommended core tobacco and alcohol
use indicators incompletely (Table 2). Some of these surveys were representative of a larger
geographic area than surveys that were already measuring tobacco use indicators completely.
As for alcohol use, some surveys provided incomplete measurements; none measured core
indicators of alcohol use completely.
Among the single-state, non-representative surveys, one measured tobacco use core indicators
completely in 20002004, but none did so in 20052009. None measured the alcohol use, diet
or physical inactivity indicators completely in 20002009 (data not shown).
Fig. 2 shows the percentage of STEPS behavioural risk factor indicators measured by the
surveys. National surveys measured 20.0% of STEPS alcohol use indicators in 20002004
and 84.6% of tobacco use indicators in 20052009, and no indicators for diet and physical
inactivity during 20002009. Overall, the percentage of STEPS indicators measured in
nationally representative and multiple-state representative surveys was somewhat higher in
20052009 than in 20002004. Seven STEPS behavioural risk factor indicators were not
measured by any survey after the year 2000 (Appendix A, available at:
http://www.phfi.org/images/Publications/journals/Raban_et_al_WHO_Bulletin_2011_Appen
dix.pdf). There were many missed opportunities for measuring STEPS indicators because the
indicator definitions used in the surveys differed from those used by STEPS (Table 3 and
Appendix A).

Fig. 2. Proportion of STEPS behavioural noncommunicable disease risk factor indicators

measured, by geographic representativeness of surveys in 20002004 and 20052009

rep, representative; STEPS, STEPwise approach to surveillance.Note: National surveys

includes those surveys that were national and representative of states or regions as well as those
that were nationally representative only; single-state surveys includes both representative and
non-representative single-state surveys.

Table 3. Number and percentage of STEPS indicators with a missed opportunity for
measurement by any surveya
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Biological risk factors
Table 2 shows the WHO-recommended core biological risk factors measured by national and
multiple-state surveys. National surveys measured only BMI in the two five-year periods we
studied, but in 20002004 only females BMI was measured. In 20052009, the
representativeness of the surveys in which blood pressure was measured improved with
respect to 20002004, but blood glucose and blood cholesterol showed no change. Singlestate surveys (data not shown) measured all biological risk factors during both five-year
periods with the exception of blood cholesterol, which was measured only in 20052009 in a
single-state survey.
Discussion
Surveillance of the major modifiable NCD risk factors in the population is essential for
programme and policy planning, implementation and evaluation. This is particularly
important for India, where the burden of NCDs has been increasing.13In this study we
examined the availability of data measuring the WHO core and STEPS NCD risk factor
indicators as collected by household surveys in India since the year 2000, and we highlight
the gaps that need to be addressed to better inform NCD control in India.
The national-level survey data collected did not adequately cover the behavioural risk factor
indicators and biological risk factors for NCDs. The WHO-recommended core tobacco use
indicators and BMI were measured in a national survey only in 20052009. Multiple-state
surveys, both representative and non-representative, filled some of the data gaps pertaining to
behavioural and biological risk factors. The data collected in 20052009 showed

improvements over the data collected in 20002004. This is not surprising since NCDs have
begun to draw more attention as a public health issue in India in recent years. However, while
many surveys included indicators of tobacco use, the remaining behavioural risk factors,
namely alcohol use, diet and physical inactivity, were covered less frequently and less
extensively. Additionally, many surveys measured the WHO-recommended core indicators
incompletely, and opportunities to measure STEPS indicators were often missed because of
the use of different indicator definitions. This underscores the need to standardize the
approach to collecting NCD risk factor data.
The biological risk factors requiring blood samples (fasting blood glucose and blood
cholesterol) were covered by surveys of smaller geographic representativeness than the
surveys that included the biological risk factors requiring physical measurement (BMI and
blood pressure). This is not surprising given that blood samples are more difficult and costly
to collect. While biological risk factor data should ideally be collected on a larger scale than
at present, it would be more practical for the health information system in India to begin by
adequately covering core behavioural risk factors, with efforts to incorporate biological risk
factors requiring physical measurements and blood samples when feasible. In this regard, the
capacity for collecting biological samples in national surveys does exist in India, as has been
demonstrated by the National Family Health Survey and the District Level Household Survey,
in which blood samples to test for anaemia and HIV have been collected.15,40 The collection
and analysis of dried blood spots on filter paper have been investigated in India in recent
years for the measurement of blood cholesterol as an easier alternative to collecting venous
blood in large surveys.41 Thus, with careful planning, blood sample collection for NCD risk
factors could be incorporated into existing national surveys in India.
Surveillance of NCD risk factors should involve periodic standardized data collection to
monitor, at appropriate levels of disaggregation, how risk factors in populations change over
time. The health information system in India includes several large-scale surveillance surveys,
but not all of them collect NCD risk factor data at present. Three rounds of the District Level
Household Surveys have been conducted, each with a sample of 530 000 to 720 000
households.40 However, the last two rounds conducted in 20022004 and 20072008 have
not collected data on NCD risk factors. The National Family Health Survey, the Demographic
and Health Survey in India, has begun including additional NCD risk factor data in the more
recent rounds, but this could be further strengthened by also covering the core behavioural
indicators and perhaps even blood pressure and blood cholesterol measurement, as in the
Demographic and Health Surveys in other countries.42 The new Annual Health Survey,
conducted in the nine least developed states of India where half of the countrys population
lives, sampled over 3.6 million households in 201043 and included some NCD risk factor
questions (results not yet published), with collection of biomarkers planned for subsequent
rounds. These three large surveys are valuable resources, particularly because they are
periodic, and they could be used to obtain the complete set of WHO-recommended core NCD
risk factors in future rounds. This would improve NCD risk factor surveillance and strengthen
Indias health information system by making it more compatible with current and projected
disease distribution, while enabling the efficient use of resources. Careful consideration of
priority indicators and their definitions would ensure standardized data collection and the core
indicators and STEPS instrument could be a useful guide for this process.
Lessons can be learnt from countries comparable to India. In Brazil, NCD risk factor
surveillance covers the STEPS behavioural risk factors and BMI.44 Several surveys

contribute to this information and a national health survey planned for 2013 will include
blood pressure and other biological risk factor measurements.44 In 2004 China initiated
nationally-representative NCD risk factor surveillance surveys that are conducted every three
years.45,46 Both countries have longitudinal data on NCD risk factors, which is also possible
in India if the collection of such data is integrated into the health information system,
particularly in national surveys.
The inability to access all survey questionnaires is a limitation of this study, since it made it
more difficult to document which indicators were measured by the surveys. Some of the
indicators that were measured could have been missed because complete data are not always
reported in publications. On the other hand, the number of indicators measured by some
surveys may have been overestimated owing to the absence of indicator definitions.
Importantly, this issue highlights the need for improved information sharing within the public
health research community to contribute to the common goal of improving population
health.47 Another limitation of the study is that only surveys with sample sizes of 5000 or
more were included in the analysis. Collecting data involving physical measurements and
blood samples is usually easier in smaller surveys. However, since all the core and STEPS
biological risk factors were collected by the surveys we examined, the exclusion of smaller
surveys is not likely to bias our main findings.
Ideally, the list of NCD risk factors to be monitored in a country should be titrated with the
countrys needs and capacity. We have suggested a shortlist of WHO-recommended core
indicators, composed of the subset of STEPS indicators that is considered measurable in lowand middle-income countries,10 as the minimum data set required for India. Measuring these
core indicators should be feasible in large-scale national household surveys in India, which
have relatively advanced capacity and are already collecting blood samples.15,40 This will
raise the cost of these surveys somewhat, but the benefits from having a complete small list of
WHO-recommended core indicators would be far-reaching and would amply justify the
expenditure. Additional STEPS indicators specifically relevant for India could also be
considered. For example, data on chewable tobacco use and bidi smoking, both of which are
highly prevalent in India, should be available. Indicators other than the WHO-recommended
core and STEPS indicators may also be necessary for comprehensive programme monitoring
and evaluation.10
NCDs are now recognized as a leading global public health problem, as demonstrated by the
convening of the United Nations Summit on NCDs scheduled for September 2011.48 As our
findings suggest, efforts to control the increasing burden of NCDs in low- and middle-income
countries involve establishing adequate systems for monitoring NCD risk factors and using
these data to refine control strategies. The methods employed in this study could be applied in
other countries to assess gaps in NCD risk factor data and integrate NCD risk factor
surveillance into national health information systems. A clear assessment of the data gaps
would be helpful in developing relevant policy for better monitoring of NCD risk factors. At
present, a lack of adequate risk factor data at the national and disaggregated levels and missed
opportunities to measure indicators owing to a lack of standardized indicator definitions
represent the most important gaps. Both could be addressed by adding appropriate
standardized NCD risk factor indicators to existing large-scale periodic surveys that are
national in scope but that can also be disaggregated to the state and regional levels.

This research highlights important deficiencies in Indias health information system. Greater
attention needs to be paid to this area of health systems research, which is largely neglected in
India, to effectively and sustainably improve the health of Indias population.49,50

Acknowledgements
We thank the many study investigators and authors who provided survey questionnaires and
information. MZR, RD and LD are affiliated with the Public Health Foundation of India, New
Delhi, India and the Sydney School of Public Health, University of Sydney, Australia. In
addition, LD is affiliated with the Institute for Health Metrics and Evaluation, University of
Washington, Seattle, USA.
Funding:
MZR was supported by an Endeavour Research Fellowship from the Department of
Education, Employment and Workplace Relations, Government of Australia, and an
Australian Postgraduate Award from the University of Sydney, Australia, for this research,
which is part of her doctorate. The funding bodies were not involved in the design, analysis or
interpretation of this research.
Competing interests:
None declared.

Communicable diseases in the South-East Asia Region of the World Health

Organization: towards a more effective response
Indrani Gupta a & Pradeep Guin a
a. Institute of Economic Growth, University Enclave, University of Delhi (North Campus),
Delhi, 110 007, India.
Correspondence to Indrani Gupta (e-mail: [email protected]).
(Submitted: 06 August 2009 Revised version received: 11 December 2009 Accepted: 11
January 2010.)
Bulletin of the World Health Organization 2010;88:199-205. doi: 10.2471/BLT.09.065540
Introduction
Although disease patterns change constantly, communicable diseases remain the leading
cause of mortality and morbidity in least and less developed countries. Despite decades of
economic growth and development in countries that belong to the World Health Organization
(WHO) South-East Asia Region (http://www.who.int/about/regions/searo), most countries in
this region still have a high burden of communicable diseases. This raises some urgent
concerns. The first is that despite policies and interventions to prevent and control
communicable diseases, most countries have failed to eradicate vaccine-preventable diseases.
Second, sustainable financing to scale up interventions is lacking, especially for emerging and
re-emerging diseases that can produce epidemics. Finally, in the present global economic and
political context, it is important to understand how international aid agencies and donors
prioritize their funding allocations for the prevention, control and treatment of communicable

diseases. Prioritization is especially critical if one accepts the global public good character of
communicable diseases.1,2
This paper analyses the current burden of communicable diseases in the region and explores
whether the current levels and trends in funding suffice to meet the needs for their control,
prevention and treatment. Our analysis considers the health Millennium Development Goals
(MDGs) and individual countries economic progress. We attempt to understand whether the
current focus of disease prevention is appropriate and to ascertain what changes in direction
might enable national and global policy-making to deal more effectively with communicable
diseases.
Communicable diseases
Disease burden
Although communicable diseases can be categorized in different ways, WHO uses three
guiding principles for prioritization: (i) diseases with a large-scale impact on mortality,
morbidity and disability, such as human immunodeficiency virus (HIV) infection and
acquired immunodeficiency syndrome (AIDS), tuberculosis (TB) and malaria; (ii) diseases
that can potentially cause epidemics, such as influenza and cholera; and (iii) diseases that can
be effectively controlled with available cost-effective interventions, such as diarrhoeal
diseases and TB.3 According to WHO data on the global burden of disease and the
distribution of diseases among countries, communicable diseases contribute slightly more to
the total disability-adjusted life years (DALYs) lost in the region (42%) than in the world as a
whole (40%).4
According to WHO,5 low-income countries currently have a relatively higher share of deaths
from: (i) HIV infection, TB and malaria, (ii) other infectious diseases, and (iii) maternal,
perinatal and nutritional causes compared with high- and middle-income countries. Although
these three causes combined pose a lesser burden than non-communicable diseases, they will
remain important causes of mortality in the next 25 years in low-income countries. In 2004,
all countries of the region except for Indonesia, Maldives, Sri Lanka and Thailand were
classified as low-income by The World Bank.
Fig. 1 shows the share of the regions contributions to world DALYs lost due to infectious
and parasitic diseases. The region bears a disproportionate share of diseases such as Japanese
encephalitis, leprosy and dengue, which have been eliminated from most of the world.
Countries of the region also contribute a higher share of DALYs due to childhood cluster and
tropical cluster diseases than the rest of the world. WHO estimates that the region contributes
27% of the global burden of infectious and parasitic diseases, 30% of respiratory infections,
33% of maternal conditions, 37% of perinatal conditions and 35% of nutritional deficiencies.
If the first two categories are included under communicable diseases, the regions
contribution to the global communicable disease burden is disproportionately high. Diarrhoeal
disease is the leading causes of death in the region and accounts for 26% of all deaths from
infectious and parasitic diseases. TB, childhood cluster diseases, HIV infection, AIDS and
meningitis are the other four major causes of death in the region. Diseases labelled as a
priority by WHO (HIV infection and AIDS, TB and malaria) are common in all 11 countries.
For example, the prevalence of HIV infection per 100 000 adult population is 982 in
Myanmar, 447 in Nepal and 1144 in Thailand. The prevalence of TB per 100 000 population
is 391 in Bangladesh, 253 in India, 244 in Nepal and 789 in Timor-Leste.6

Fig. 1. Share of world DALYs due to infectious and parasitic diseases corresponding to the
South-East Asia Region of the World Health Organization, 2004

DALYs, disease-adjusted life years; STDs, sexually transmitted diseases.The data were obtained
from the World Health Organization.4

Table 1 shows the annual incidence of selected communicable diseases in the world and in the
region. Some of the highest annual incidences worldwide of diarrhoeal diseases, lower
respiratory infections, malaria, measles and dengue appear in the region. The percentage of
the worlds disease burden contributed by countries of the region is 64 for measles, 36 for TB,
33 for upper respiratory infections, 52 for dengue and 28 for diarrhoeal disease.7 Clearly,
communicable diseases present a mixture of challenges for the region, with a variety of them
falling under all three WHO categories mentioned above: diseases with high mortality and
morbidity, those that can potentially cause epidemics and those that can be controlled with
available and proven interventions.
Table 1. Annual incidence of selected communicable diseases worldwide and in the SouthEast Asia Region of the World Health Organization, 2004a
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National and regional variations
The share of total DALYs lost due to communicable diseases is higher than the regional
average (approximately 30%) in Bangladesh (48%), India and Bhutan (44% each), Myanmar
(46%), Nepal (49%) and Timor-Leste (58%). In contrast, this proportion is lower than the
regional average in Sri Lanka (15%), and similar to it in the Democratic Peoples Republic of
Korea, Indonesia, Maldives and Thailand.
Relatively older diseases such as TB, malaria, cholera and meningitis have recently
recrudesced worldwide. At the same time, newer or re-emerging diseases such as infection
with influenza A (H5N1) virus (avian flu), severe acute respiratory syndrome (SARS) and
chikungunya have reached epidemic proportions in some countries. Many countries are also
facing the rapid spread of infection with influenza A (H1N1) virus (i.e. pandemic influenza).
In the region, Thailand has reported the most deaths from pandemic influenza, and India and
Indonesia have reported a fairly rapid increase in the number of cases. In 2007, India and
Indonesia were among the top five countries in the region in terms of the total number of TB

cases.8 As for multidrug resistant TB, India contributes the most cases in the region, with
Bangladesh ranking fifth.
The five infectious and parasitic diseases that contribute the most DALYs lost are generally
the same in all countries of the region although variations in the rank order exist. The topranking contributor is lower respiratory infections in 8 out of 11 countries; HIV infection and
AIDS in Thailand, TB in Indonesia, and malaria in Timor-Leste. Countries of the region are
thus facing huge challenges from diseases generally associated with underdevelopment,
poverty and a less-than-effective health system, as well as from emerging infectious
diseases.4
Disease priorities
In-country estimates of disease burdens are the best tools for guiding prioritization, but a
reliable analysis of how countries set their priorities is not easy because information and data
are lacking on internal processes that lead to resource allocation. Unfortunately, ongoing
burden of disease calculations are still not a priority in the region, and sustainable technical
expertise for these analyses is also lacking. National health accounts, if available, are of some
help but may not in themselves make comprehensive accounting of resource allocations for
communicable diseases possible. Also, not all countries in the region have national health
accounts in a format that allows comparisons of aggregates across countries, and this is true
for communicable diseases. If functional allocations are assumed to be indicators of
prioritization, then countries appear to be giving different weights to communicable diseases.
For example, total health expenditure on the prevention and control of communicable diseases
in India (1.4%) is half the amount Sri Lanka allocates.9,10
Another approach to prioritization is to use inputs from international agencies such as the
Global Fund to Fight AIDS, Tuberculosis and Malaria. Most countries in the region now have
Global Fund resources for the prevention and treatment of these three diseases. Although this
funding should be used for additional activities and interventions, there are no data or
analyses that clarify whether they have complemented or substituted for the resources
regularly allocated to communicable diseases.
Disease prioritization is also implicit in MDGs 4, 5 and 6: to reduce child mortality, improve
maternal health and combat HIV infection, AIDS, malaria and other diseases, respectively.
Because most discussions of MDGs centre on Goal 6, attention is detracted from other
conditions whose reduction would lead to a lower burden of communicable diseases. For
example, improving maternal health would have a direct, positive impact on child health and
reduce child mortality. Although Goal 6 embraces other diseases, in operational terms it
includes only TB in addition to malaria, HIV infection and AIDS.11,12 If all three MDGs
were addressed seriously, countries would see a reduction in communicable disease
incidence. However, it is not clear whether funds are effectively allocated to the various
diseases comprised by the three MDGs. For example, there are large global funding windows
for the diseases targeted by Goal 6 but fewer windows for childhood disease interventions
that go beyond vaccination and attempt to address other fundamental health and development
sector issues. Current funding criteria may thus limit the effectiveness of existing strategies.
Addressing other MDGs, such as the eradication of poverty and hunger, would also go a long
way towardsmeeting health-centred MDGs. In the region, HIV infection is concentrated
among populations that are marginalized, have adverse human development indicators and
are mobile mostly because of economic reasons. Similarly, TB is seen to affect the
marginalized, discriminated against populations, and people living in poverty.13 Malaria

disproportionately affects the poor, especially because its cause is linked to livelihood,
migration and living conditions.14,15 However, other communicable diseases are also linked
to poverty and underdevelopment. For example, undernutrition is an underlying cause of child
deaths associated with diarrhoea, pneumonia, malaria and measles.16
A look at the contributions from the region to world DALYs lost on account of different
infectious and parasitic diseases (Fig. 1) shows that diseases prioritized by MDG 6 HIV
infection and AIDS, TB and malaria are actually among the lowest-ranked. In contrast,
Japanese encephalitis, leprosy, dengue and childhood cluster diseases in the region contribute
much more to the total DALYs lost globally.
Eradication of vaccine-preventable diseases could reduce disease burdens effectively. An
analysis of data from 97 developing countries shows that immunization coverage is a
statistically significant predictor of the infant mortality rate.17 The negative association
between the latter and immunization coverage was also established in successive National
Family Health Surveys in India.18 Although routine vaccination coverage has reached high
levels in many south-east Asian countries, others, such as India, Indonesia, Myanmar and
Timor-Leste, have not achieved full coverage.
With vector-borne diseases on the rise, there are concerns about the ability of resourcedeficient countries to combat large outbreaks. The prevention of outbreaks itself is
challenging because of their complex determinants. This situation makes developing countries
especially susceptible because the health sector can only play a relatively small role in
prevention.19,20 The lack of a good disease surveillance system and the inadequacy of the
primary care infrastructure compound the problems and make prevention, control and
treatment of vector-borne diseases an urgent challenge.3,21
Although progress towards the MDGs seems to be on track for HIV, TB and malaria in many
countries of the region, realistic goals in the light of economic growth patterns, development
paradigms and health sector realities should include all other major health conditions that
affect these countries. It might be more relevant for countries to individually redefine the
objectives established for MDG goals 4, 5 and 6 in accordance with their particular realities
and disease burdens.
The global economic crisis
According to a recent study of 25 developing countries,22 a decrease in the growth rate of
gross domestic product (GDP) by three percentage points in Asia and the Pacific is likely to
translate into 10 million more undernourished people, 56 000 more deaths among children < 5
years old, and 2000 more mothers dying in childbirth. Moreover, this decline was predicted to
delay the achievement of MDG targets relating to infant mortality and hunger by one year.
This finding is important in the context of the recent global financial crisis. Among the 11
countries of the region, the non-financial or real sectors in countries such as the Democratic
Peoples Republic of Korea, Indonesia, Timor-Leste and Thailand are much more affected by
the global crisis compared to countries in South Asia. The impact of the recession on health
spending and health outcomes, and hence on the control of communicable diseases, will be
seen in several areas.23 (i) For example, overall budget cuts will result from a shrinking tax
base and declining official development assistance. (ii) A possible impact on global health
funding for communicable diseases might, in turn, affect national disease control
programmes. (iii) Increased poverty and unemployment and declining incomes will lead to
unfulfilled or delayed demand for treatment and poorer health outcomes. (iv) Increased

subsidies will be needed to combat increased fuel and food prices. (v) Finally, the prices of
essential drugs and medical goods will increase.
A comparison of the percentage of GDP spent on health in the region (Fig. 2) shows that
Timor-Leste and Maldives have been successful in raising resources for health over the years,
whereas most other countries have been less successful. India has been able to increase health
spending slightly since 2000. Indonesia and Myanmar have a very low ratio of health
spending to GDP, whereas the rest of the countries are somewhere in-between. The overall
level of health spending, in turn, determines how much spending will potentially be available
for communicable diseases. Therefore the data strongly suggest that financing for
communicable diseases will remain a source of worry, especially for countries most severely
affected by the financial crisis.
Fig. 2. Total expenditure on health as a percentage of gross domestic product in countries of
the South-East Asia Region of the World Health Organization, 19952006

The data were obtained from the World Health Organization.6

For countries that depend on external funding, the decrease in aid is a major worry. Aid
diminishes during economic crises and sometimes does not recover fully to earlier levels.24 A
large part of the funds for communicable diseases come from international donors and private
foundations based in developed countries. Therefore the current crisis will also have an

impact on this flow, which in turn will have a disproportionate impact on communicable
diseases programmes.
Countries such as Maldives and Timor-Leste need to prepare for the effect of decreasing aid
on their health sectors. Bhutan is somewhat less dependent on external funding and may
therefore be able to escape the impact of declining aid. Although the current crisis has not
significantly affected overseas development assistance in Nepal,25 the impact on
communicable diseases linked to or aggravated by poverty and poor living conditions is likely
to be severe enough to warrant serious attention from aid agencies. Myanmars economic
growth has not translated into health sector gains, and this country also depends on foreign
aid to augment its resources. Similarly, Bangladesh already faces increasing poverty and
adverse health indicators, and the current crisis is likely to worsen the situation. Stimulus
packages, implemented by some countries, may be needed.26 Maldives, a much smaller
country, is in a better position to cope with the impact of the crisis since it has already
received stimulus measures from domestic and international organizations. Timor-Leste,
which is heavily dependent on aid, will need help to maintain its levels of investment in the
health and social sectors.
The impact of shrinking economic growth and aid on vulnerable populations has direct
implications for communicable diseases programmes. Global financing to fight
communicable diseases is not always aligned with the disease priorities of developing
countries, and since donors tend to imitate each others funding decisions, the real needs of
developing countries may be overlooked.27 Applying the concept of global public good to
health funding decisions would help reprioritize financing for communicable diseases and
eliminate the distortions caused by disease-specific funding.2 These priority issues are more
relevant now that economic growth, especially in many donor countries, has slowed
significantly.
Discussion
The global response to the financial crisis has been to maintain the quantity of aid to the
extent possible, so as not to jeopardize progress towards the MDGs.28 For example, The
World Bank is planning to triple the loans it provides to the health sector.29 However,
inefficiencies and inadequate management within the health sector in many countries of the
region reduce the effectiveness of aid. The issue of aid effectiveness has now received serious
attention from development agencies, and among the concerns are the lack of harmonization
and alignment, problems with predictability and the need for common arrangements and
procedures.30 A high-level WHO consultation on the impact of the global crisis on
health31,32identified the need to make health spending more effective and efficient and to
ensure adequate aid levels.
As has been powerfully stated, every change in demography, vegetation, land use,
technology, economics and social relations is also a potential change in the ecology of
pathogens and their reservoirs and vectors and therefore a change in the pattern of infectious
disease epidemiology.33 Preventing and responding to traditional, emerging and reemerging communicable diseases is therefore a complex endeavour that will not succeed if it
is limited to simply increasing the funds available to fight selected diseases. In times of
financial crisis it is important for donor countries to find innovative solutions to enhance the
effectiveness of their reduced volume of aid.34
Although the 11 countries of the region are on different trajectories of growth and
development, their struggle to eliminate underdevelopment and poverty has driven them to a

high-growth strategy. However, high-growth policies are increasing the population vulnerable
to communicable diseases. Clearly, economic growth alone is not the solution. The
2009 Global monitoring report of the International Monetary Fund and The World Bank calls
the current crisis a development emergency because the potential increase in vulnerable
populations may delay progress in the fight against communicable diseases.35
Funding needs to be much more carefully matched to disease and health system priorities in
each country. Although the MDG health goals are important benchmarks, programme goals
should be more relevant, inclusive and realistic. They should be multisectoral and take into
account both the realities of the health sector and the development path chosen by the
country. Global health and development initiatives need to expand their focus to include
diseases and conditions that are less well known or less discussed, while at the same time
addressing socioeconomic and health sector constraints in each country. This approach would
go a long way towards making aid more effective. Moreover, it would make donors and
policy-makers more aware of traditional vaccine-preventable childhood diseases, traditional
and emerging vector-borne diseases and respiratory infections, which remain among the most
important contributors to high disease burdens in the WHO South-East Asia Region.
Ultimately, countries should set their own priorities for the prevention, control and treatment
of communicable diseases. It is up to each country to convince the world of where its
priorities lie. The global public good character of some communicable diseases warrants
concerted world action. Nevertheless, significant gaps in funding as well as regional
variations require a more diverse set of national and international aid measures. Although
regional and global collaboration is critical, future policies for reducing the burden of
communicable diseases in the region will only be affective if they are based on evidence and
country-led.