Capitalizing on the Demographic Transition


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For decades, the leading causes of mortality have differed between low income countries and high income countries. Those who have worked their careers in health and development probably never thought they would see the day when maternal/child health and communicable diseases would not be the leading health burden in many low income countries.

The new actor is non-communicable diseases (NCDs), which are characterized by chronic diseases (cardiovascular disease, diabetes, cancer, and chronic respiratory disease), along with injury and mental health which are now responsible for half the health burden in South Asia. Thus, the challenge now is how best to juggle this “double burden”.

Currently, many compelling reasons are pushing countries toward starting to tackle NCDs. From both a social and political standpoint, South Asians are 6 years younger than those in the rest of the world at their first heart attack. This type of trend threatens a country’s ability to fully capitalize on the demographic dividend from a larger mature working force because healthy aging is necessary, which in turn, requires tackling NCDs.

NCDs have gain attention across the spectrum with the World Economic Forum’s Global Risks Report for both 2009 and 2010 has put chronic NCDs and their impact on both advanced and developing economies high on its Global Risk Matrix because of their connection to other global risks such as financial crises and underinvestment in infrastructure.

While the future increase in the disease burden and risk factors will both put a strain on service delivery and stress budgets, many opportunities for their prevention and control are available. Experience from developed countries indicates that the increase in cardiovascular disease during a similar phase of the epidemiologic transition could be blunted and even dramatically reduced by changes in risk levels within the population and through improving primary care for NCDs.

Until now, there has not been a holistic work exploring the factors and solutions to NCDs in the region. This is why the World Bank’s first South Asia Report on the issue will be launched on Wednesday, February 9th across the region. We will keep you updated on its findings through this blog throughout the next two months and will include specific issues and solutions for Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka.

For now, we have three questions in mind:

• What has been your experience with non-communicable diseases in South Asia?

• What lifestyle choices would you suggest people adopt to live longer, healthier lives?

• What policies would you like to see countries adopt to respond to this issue?

What do you think? Do let us know if you have any questions.

Read the Report here



Michael Engelgau

Senior Health Specialist

Join the Conversation

Sundararajan S. Gopalan
February 02, 2011

The Regional study on NCDs (along with a separate more detailed study on Sri Lanka) is being launched not a day too early. Strong advocacy on this issue is long overdue and we have to hope that these reports will add impetus to the recognition that communicable diseases (CDs) and MCH issues are not the only significant public health problems even in the low-income countries (LICs) of South Asia.

There are lots of specific technical points related to the topic. But I would highlight just three important policy considerations:

a) tackling NCDs while the CDs and MCH issues need not be a zero-sum game. Yes, additional resources would be required to carry out activities (e.g., screening for NCDs, providing long-term care and medication to keep risk factors such as cholesterol or blood sugar under control) which have traditionally been absent even in the best-designed package of "essential" health services that most LICs have been focusing on. And yes, compared with the cost of controlling infectious diseases, the NCD control and prevention costs could seem unaffordable by LICs. But if resource allocation and program implementation are done smartly, much of the systemic improvements can contribute to the control of both types of diseases.

b) under-nutrition, especially in the very early ages, might well be the rallying point that links CDs and NCDs. As evidence is being increasingly reported that such under-nutrition can result in higher NCD risk in later life, we have always known the connection between under-nutrition and childhood infections. So, in light of the new recognition of the NCD burden, program managers dealing with CDs, MCH and NCDs are bound to fight over limited resources (notwithstanding the first point about this not being a zero-sum game); but addressing childhood under-nutrition is a cause that all of us can immediately agree upon.

c) though certain NCDs have certain commonalities - in terms of risk factors, and strategic actions needed - it is important to recognize that NCD is a very broad-brush description of a host of very disparate conditions (ranging from cancers to cardio-vascular to endocrine disorders to injuries to mental illnesses). Therefore, while studying the NCD burden is a useful approach - especially in the context of the demographic and epidemiological transition - for enhancing awareness and aiding the necessary advocacy for policy actions, and some strategies such as tobacco control or reduction of overweight could help control more than once NCD, when it comes to specific actions, many individual NCDs will require individually tailored strategies.

February 02, 2011

How can someone in New York City get to read this 1st South Asia Report by World Bank?

Joe Qian
February 03, 2011

The report will be available online in PDF form on Wednesday, February 9th. We will have the link available on the blog as well as the World Bank's South Asia website.

Rajeev Gupta
February 09, 2011

We have recently published an article in BMC journal Health Research Policy and Systems on policy issues to tackle the rampaging CVD epidemic in India. This may be useful to policy makers and administrators. The abstract reads as follows:
Cardiovascular diseases (CVD) are leading causes of premature mortality in Ind
ia. Evidence from developed countries shows that mortality from these can be substantially prevented using population-wide and individual-based strategies. Policy initiatives for control of CVD in India have been suggested but evidence of efficacy has emerged only recently. These initiatives can have immediate impact in reducing morbidity and mortality. Of the prevention strategies, primordial involve improvement in socioeconomic status and literacy, adequate healthcare financing and public health insurance, effective national CVD control programme, smoking control policies, legislative control of saturated fats, trans fats, salt and alcohol, and development of facilities for increasing physical activity through better urban planning and school-based and worksite interventions. Primary prevention entails change in medical educational curriculum and improved healthcare delivery for control of CVD risk factors- smoking, hypertension, dyslipidemia and diabetes. Secondary prevention involves creation of facilities and human resources for optimum acute CVD care and secondary prevention. There is need to integrate various policy makers, develop effective policies and modify healthcare systems for effective delivery of CVD preventive care.
The full article is available free at the journal website.

Nachiket Mor
February 06, 2011

Dear Dr. Englegau,

It would be wonderful to read World Bank's South Asia NCD report and I look forward to doing so. Colleagues of mine in have been working on the ground to develop new primary care models for NCDs and from their early design work in Thanjavur find that some components are key to success here:

1. The presence of a good primary care facility at the community level (within a half hour walking distance) with access to good diagnostics and trained medical personnel (a Nurse Practitioner would be ideal here -- MBBS Doctors tend to get bored with the routine very quickly and are not very amenable to following tight protocols).

2. Structured screening of every individual in the community using multiple low-cost and non-invasive methods followed by referral to the nearby primary care facility which follows very carefully specified protocols and uses a high quality Electronic Health Records System to track patient data and progress.

3. Carefully executed evidence based community level protocols relating to NCDs.

4. Strong referral and financial protection measures combined with good financial inclusion provided by local financial institutions.

Early evidence from their clinics and health extension workers suggest that the costs of implementing these interventions is very low and even the training challenges are pretty modest once the systems and processes are set up and the relevant information technology infrastructure and protocols are put in place.

To learn more about their work please do take a look at: We look forward to receiving comments on our approach.


Nachiket Mor

Joe Qian
February 09, 2011

Thank you all for your very insightful comments.

The report is now available online at:

Michael will be writing a followup blog entry on the report which will be online in the next few days.

Michael Engelgau
February 10, 2011

The wind in the NCD sails is coming up. A window is opening that should allow for some great steps forward and get some badly needed, timely, attention.

In Sept 2011, the United Nations will have a General Assembly Special Session on NCDs. Leading up to this session there are many other meeting including a WHO sponsored meeting in Jarkata, Indonesia, in March, and, in April, a Ministerial meeting in Moscow, Russia.

In South Asia, a video-conferenced strategic discussion of the NCD report included all 8 South Asian countries (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) and found much energy across the region to be come more engaged and to have a voice in the upcoming global discussions on NCDs.

This type of opportunity does not come often - and the momentum is building up.

In response to Nachiket Mor comments, good primary care will play a key role in reducing the complications among those who already have disease. However, in addition to treatment, population-level prevention is a vital element. A balance between prevention and treatment is needed. We know this from developed countries experiences with NCDs over the last half century. The dramatic declines heart disease deaths in developed countries over this time period were roughly half due to population level change in risk and half due to primary care types of treatments. The challenge is getting the best strategic balance for a country's context.

Some real opportunities are out there.

Dr. Michael Duenas
April 17, 2012

Dear Dr. Michael Engelgau,

It is wonderful to see this great work. I fully support the argument that the epidemiologic transition of non-communicable diseases (NCDs) could be blunted and even dramatically reduced by through improving primary care for NCDs. The strength of this association is reliant on early intervention and access to a full range of essential primary care.

One area of essential primary care type of treatment that is cost effective, of high value and directly tied to NCDs, but often overlooked, is comprehensive primary vision health/optometry services.

The importance of this essential comprehensive service is based on the diseases have important eye findings that can be detected during a comprehensive eye examination, thereby providing unique treatment and coordinating potentials, at the various life stages, (A) Infants and Toddlers ;( B) Children; (C) Adolescents ;( D) Young Adults; (E) Older Adults and Seniors, as indicated below.

NCDs tied to eye care / Most to Least Common: (ICD-9-CM Codes)

1. Diabetes (250-259) (Type 1, Type 2)
2. Hypertension (401) LS/ C,D,E
3. Arteriolosclerosis/Hardening of the Arteries (440.9) LS/D,E
4. Vessel Occlusive Diseases (430-438) (440) LS/D,E
5. Raised Intracranial Pressure LS/ A,B,C,D,E
6. Sjögren’s Syndrome (710.2) LS/D,E
7. Migraine (346) LS/B,C,D,E
8. Thyroid Dysfunction (242.0) LS/ C,D,E
9. Hyperviscosity Blood Syndromes
10. Rheumatoid Arthritis (714) LS/ D/E
11. Dermatitis Atopic (691) LS/A,B,C,D,E
12. Acne Rosacea (695.3) LS D,E
13. Pre-Diabetes/ IFG/ IGT) LS/ B,C,D,E
14. Psoriatic Arthritis (716.9) LS/D,E
15. Gout (274.8) LS/E
16. Sinusitis Chronic (473.0) LS/C,D,E
17. Pituitary Tumors (194.3) LS/C,D,E
18. Sarcoidosis (135.0) LS/D,E
19. Ankylosing Spondylitis (720) LS/ D,E
20. Juvenile Rheumatoid Arthritis LS/B,C,D,E
21. Meningitis (320) (321) LS/ A,B,C,D,E
22. Systemic Lupus ( 710.0) LS/D,E
23. Scleroderma (710.1) LS/D,E
24. Reiter’s Syndrome (099.3) LS/E
25. Sturge-Weber Syndrome (759.6) LS/A,B,C,D,E
26. Neurofibromatosis LS/A,B,C,D,E
27. Myasthenia Gravis (358.00) LS/C,D,E
28. Marfans Syndrome (090.49) LS/A,B,C,D,E
29. Down’s Syndrome (758) LS/A,B,C
30. Behcet’s Disease (136.1) LS/D,E
31. Usher’s Syndrome LS/ A,B,C,D,E
32. Crohn’s Disease (555.9) LS/ D,E
33. Pseudoxanthoma Elasticum LS/ D,E
34. Stevens-Johnson Syndrome (695.1) LS/C,D,E
35. Albinism (270.2) LS/A,B,C,D,E
36. Anemias (280-289) LS/ A,B,C,D,E
37. Nerve Diseases and Palsies (350-359) (Third, Fourth, Sixth, Seventh) LS/ D,E
38. Leukaemias (200-208) LS/A,B,C,D,E
39. Other Cancers ( 190.0) (216.1) (224.0) LS/A,B,C,D,E
40. Vitamin A Deficiency (268) LS/ B,C,D,E
41. Multiple Sclerosis (340) LS/ C,D,E

Thus, in describing the challenge of how best to juggle this “double burden”, access to a comprehensive eye examination may provide earlier detection, timelier treatments and reduced disabilities and deaths associated with a number of NCDs that disproportionately burden these vulnerable South Asia populations.

Additionally, enhanced disease prevention opportunities exist beyond NCDs based on eye findings linked to certain behaviors. As an example, cigarette smoking, use of other tobacco products, engaging in unprotected sex, the excessive use of alcohol, IV drug use, excess UV exposure, repeated use of certain drugs or drug combinations, all have specific eye findings that would provide additional opportunities for patient education ,council and access to treatment. Hopefully this understanding can aid countries in finding the optimum ballance for the healthof thier populations.

Michael R. Duenas, O.D.
Chief Public Health Officer, American Optometric Association
[email protected]