What is Happening and Its Implications?

Context 

South Asia is home to a large, fast-growing population with a substantial proportion living in poverty. In
terms of the demographic transition, it is still relatively young, while the regional average life expectancy
at birth, 64 years, is rising. Most people live in rural areas (71 percent).2 Despite annual average
6 percent gross domestic product (GDP) growth in the last 20 years and declines in poverty rates,
growth has not been inclusive or fast enough to reduce the number of the poor. Inequality has risen,
reflecting deep distortions in access to markets, and in access to and quality of health, education, and
infrastructure. These factors have contributed to mixed progress on the health-related Millennium
Development Goals, as has the failure of health systems to adjust to people’s changing needs. There is
tremendous variation in population size among countries, yet all countries have similar proportions
living in rural areas and significant pockets of poverty—an important point, not only for considering the

challenges of addressing social determinants and NCDs but also the challenges of delivering services.
 
Aging and the Shifting Disease Pattern
Aging is occurring rapidly but often without the social changes such as improved living conditions, better
nutrition, gains in wealth, and better access to health services that accompanied aging in most
developed countries decades ago. Aging due to this transition will, alone, increase NCDs because they
are more common with increasing age. However, population aging in South Asia is associated with a
rapid increase in health problems such as heart diseases, cancers, diabetes, and obesity—in other
words, unhealthy aging—putting new pressure on health systems. Other factors—including lifestyle
changes that are often associated with urbanization and globalization—can also increase the risk factors
and disease onset at younger ages.

South Asia is at a crossroads. Over half of the disease burden (55 percent including injuries) is now
attributable to NCDs, and therefore a larger share than communicable diseases, maternal and child
health issues, and nutritional causes combined. This pattern is similar to that of high-income countries
decades ago. Ischemic heart disease (IHD) is the leading cause of both deaths and forgone disabilityadjusted
life years (DALYs) in working-age adults (15–69 years). By contrast, communicable diseases
(e.g., tuberculosis, respiratory infections, and water- and vectorborne disease) still remain prominent in
the total population creating what is referred to as a “double-disease burden.”
 
Country-level Contexts
Various country-level contextual factors need consideration for developing effective responses. Country
NCD disease burdens are quite variable. Of the total DALYs forgone attributed to NCDs, the proportion
ranges from 87 percent in Sri Lanka to 43 percent in Afghanistan. Where trend data are available, they
indicate that the prevalence of NCDs is increasing (for example, diabetes in Sri Lanka). In contrast to the
disease burden, some NCD risk factors (for example, tobacco use) vary relatively little across the region.
It is among the poor where the combination of NCD risk factors and infectious diseases are more
common, leading to worse outcomes. For instance, the risk of dying from tuberculosis is 2.3 times as
high for smokers as nonsmokers, while both tuberculosis incidence and tobacco use are higher among
the poor.

This regional pattern of a similar NCD risk factor burden and variable country disease burden, occurs for
two related reasons. First, the period between chronic NCD risk factor exposure and its related
morbidity and mortality is long, especially compared to most infectious diseases. Second, in countries
with lower life expectancy, people die from other causes (that is, infectious diseases) at younger agesbefore the full impact of exposure to NCD risk factors occurs. Thus, in countries where infectious
diseases remain a significant cause of mortality, smokers may succumb to other causes before tobacco’s
ill effects manifest themselves. By contrast, in countries with longer life expectancies and where tobacco
users smoke for many years, the ill effects of tobacco may ultimately cause significant morbidity or even
death.

Low birth weight, still common in South Asia, is an important risk factor for NCDs. The fetal origins
hypothesis of adult diseases postulates that fetal undernutrition, reflected by low birth weight, is
associated with susceptibility to development of IHD and other chronic NCDs in later life.
In socioeconomic terms, the poor face multiple obstacles in preventing NCDs. Tobacco use rates tend to
be higher among men with less or no education and tobacco expenditure among the poor frequently
crowds out spending on food and education. Furthermore, as noted, it is among the poor where
infectious diseases, such as tuberculosis, concomitant with NCDs can result in worse outcomes.
Clustering of NCD risk factors is common. While data limitations do not allow examination of South Asia,
multiple risk factors, such as high blood pressure, high cholesterol, high glucose, and obesity, frequently
occur in the same individual.

The economic impact of NCDs is significant. In terms of macroeconomic costs, if NCDs were completely
eliminated, estimated GDP could increase by 4–10 percent. While elimination is not feasible nor a
current, realistic goal, these finding give a sense of the impact that interventions might have. In terms of
microeconomic costs, about 40 percent of household expenditures for treating NCDs are financed by
household borrowing and sales of assets, indicating significant levels of financial vulnerability to NCDs.
The odds of incurring catastrophic hospitalization expenditures are nearly 160 percent higher with
cancer, than the odds of incurring catastrophic spending when hospitalization is due to a communicable
disease. Because of the chronic nature NCDs compared to communicable diseases, recurrent health
events increase the risk of more frequent catastrophic spending. Thus, governments’ efforts to reduce impoverishment due to illness may be influenced heavily by policies related to NCDs.

Implications 
These findings have major implications for South Asia. Aging will not only increase NCDs, but with it
occurring rapidly and without associated economic gains nor social support systems, it can lead to
unhealthy aging, characterized by disability and premature death—resulting more quickly in less
favorable dependency ratios. The shift of the disease burden toward NCDs—while a significant burden
remains of maternal and child health and nutrition issues—will increase demand on the health system
because of the need to address this double-disease burden. With most health care currently financed
with private out-of-pocket resources, this burden on households will make it harder for many to escape
poverty while more will be driven into poverty. Many households may well forgo treatment and suffer
excessively, or skew their expenditure patterns from other human development investments such as
education (or adopt a combination of the two approaches).

As rural populations shift toward urban areas they will experience changes in lifestyles that may increase
their NCD risks. Extreme poverty and fetal and early childhood undernutrition, both from the current
situation and from past exposures, will create a large pool of those at elevated risk.