The Epidemiological transition—the shift from infectious and deficiency diseases to chronic non communicable diseases—was a unidirectional process, beginning when infectious diseases were predominant and ending when non communicable diseases dominated the causes of death. It has, however, become apparent that this transition is more complex and dynamic: the health and disease patterns of a society evolve in diverse ways as a result of demographic, socioeconomic, technological, cultural, environmental and biological changes. It is rather a continuous transformation process, with some diseases disappearing and others appearing or re-emerging. This also indicates that such a process is not unidirectional

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Introduction and background
Over time, mortality and disease patterns in human populations transition from very
high and fluctuating mortality concentrated at younger ages and largely caused by
infectious diseases and nutritional deficiencies to relatively stable low mortality
concentrated at older ages and largely caused by non-communicable diseases and
injuries – the ‘epidemiological transition’ [1]. High-income countries experienced
this transition in an orderly way along a unidirectional path during the first half of
the twentieth century [1]. The first phase of the transition was characterized by high,
fluctuating mortality dominated by epidemics of infectious diseases, famines and
wars. Thereafter, mortality rates declined progressively and degenerative diseases
started to replace infectious diseases as the major causes of morbidity and death.
Finally, in later stages of the transition, non-communicable diseases such as
cardiovascular diseases, diabetes and cancers, and accidents became the main causes
of death, and mortality rates eventually stabilized at relatively low levels [1,2,3].
In low- and middle-income countries the epidemiological transition is still underway
and its progress is more varied compared to the experience of high-income countries.
Observed changes in mortality and disease patterns in most low- and middle-income
countries including those in sub-Saharan Africa reveal transitions that are
characterized by reversals, partial changes and simultaneous occurrence of different
types of diseases
Omran divided the epidemiological transition of mortality into three phases, in the
last of which chronic diseases replace infection as the primary cause of death. These
phases are:
1. The Age of Pestilence and Famine: Mortality is high and fluctuating,
precluding sustained population growth, with low and variable life
expectancy vacillating between 20 and 40 years. It is characterized by an
increase in infectious diseases, malnutrition and famine, common during

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the Neolithic age. Before the first transition, the hominid ancestors
were hunter-gatherers and foragers, a lifestyle partly enabled by a small and
dispersed population, however unreliable and seasonal food sources put
communities at risk for periods of malnutrition.
2. The Age of Receding Pandemics: Mortality declines, with the rate of decline
accelerating as epidemic peaks decrease in frequency. Average life
expectancy increases steadily from about 30 to 50 years. Population growth
is sustained and begins to be exponential.
3. The Age of Degenerative and Man-Made Diseases: Mortality continues to
decline and eventually approaches stability at a relatively low level. Mortality
is increasingly related to degenerative diseases, cardiovascular
disease (CVD), cancer, violence, accidents, and substance abuse, some of
these due primarily to human behavior patterns. The average life expectancy
at birth rises gradually until it exceeds 50 years. It is during this stage that
fertility becomes the crucial factor in population growth.
In 1998 Barrett et al. proposed two additional phases in which cardiovascular
diseases diminish as a cause of mortality due to changes in culture, lifestyle and diet,
and diseases associated with aging increase in prevalence. In the final phase, disease
is largely controlled for those with access to education and health care, but
inequalities persist.
1. The Age of Declining CVD Mortality, Aging and Emerging Diseases:
Technological advances in medicine stabilize mortality and the birth rate
levels off. Emerging diseases become increasingly lethal due to antibiotic
resistance, new pathogens like Ebola or Zika, and mutations that allow old
pathogens to overcome human immunity.
2. The Age of Aspired Quality of Life with Persistent Inequalities: The birth rate
declines as lifespan is extended, leading to an age-balanced population.

4. 3 | P a g e
Socioeconomic, ethnic, and gender inequalities continue to manifest
differences in mortality and fertility.
The epidemiological transition occurs when a country undergoes the process of
transitioning from developing nation to developed nation status. The developments
of modern healthcare and medicine, such as antibiotics, drastically reduce infant
mortality rates and extend average life expectancy which, coupled with subsequent
declines in fertility rates, reflects a transition to chronic and degenerative diseases
as more important causes of death. [1].
The health and disease patterns of a society evolve in diverse ways as a result of
demographic, socioeconomic, technological, cultural, environmental and biological
changes. It is rather a continuous transformation process, with some diseases
disappearing and others appearing or re-emerging. This also indicates that such a
process is not unidirectional. In fact, a reversal of the trend sometimes occurs. There
are some outstanding examples, such as the emergence of new infectious diseases
like AIDS, and the increase in infections that were previously controlled, such as
tuberculosis and dengue fever.
It is also important to note that several stages of transition may overlap in the same
country. For example, the decline in infectious diseases may be slow or stagnant
among some sectors of the population while noncommunicable diseases may be
increasing rapidly in another sector of the same population. This is still happening
in many societies of the Eastern Mediterranean Region where the less affluent
sectors have a high incidence of infectious diseases among children while the
wealthier sectors show completely different patterns of illness.
Demographic changes are a composite of changes in both mortality and fertility. As
populations become healthier, a reduction in mortality, particularly of infants and
children, usually occurs, followed later by a fall in fertility rates. Therefore, more
people will survive to adulthood and will have the disease patterns of adults, with
noncommunicable diseases at the top of list. They will also be exposed to diseases

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that more frequently affect elderly people, such as cancer and cardiovascular
diseases. Thus, even with constant age-specific incidence rates of noncommunicable
diseases, the absolute number of cases and deaths from these diseases increases
substantially with the above-mentioned demographic change.
The risk factors involved in the epidemiological transition include biological factors
(microorganisms), environmental factors, social, cultural and behavioral factors and
the practices of modern medicine.
It is well known that microorganisms constantly undergo changes that enable them
to cope with an increasingly hostile environment. In fact, the development of
mechanisms that permit survival of the most adaptable microorganisms is more
rapid than the development of defense mechanisms that allow their hosts to combat
microbial invaders. This adaptive process involves finding and exploiting
weaknesses in the defenses of the host and can happen by means of several
mechanisms: alteration in antigenic identity, emergence of drug-resistant strains and
dual infection. The development of resistance is not restricted to microbes but also
occurs with parasites. The development of resistance of the malaria parasite to
chloroquine has been and is still one of the main causes of setbacks in malaria
control programmes. [4].
Conceptually, the theory of epidemiologic transition focuses on the complex change
in patterns of health and disease and on the interactions between these patterns and
their demographic, economic and sociologic determinants, and consequences. An
epidemiologic transition has paralleled the demographic and technologic transitions
in the now developed countries of the world and is still underway in less-developed
societies. Ample evidence may be cited to document this transition in which
degenerative and man-made diseases displace pandemics of infection as the primary
causes of morbidity and mortality. What begins as an apparently academic exercise,
attempting to describe and disentangle the determinants and consequences of
changing disease patterns that have accompanied modernization in most western
countries,[5].

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Epidemiological transition ratio is defined as the ratio of DALYs caused by
Communicable, Maternal, Neonatal and Nutritional Diseases (CMNNDs) to those
caused by Non-Communicable Diseases (NCDs) and injuries. A ratio greater than
one indicates a higher burden of CMNNDs than NCDs and injuries, while a ratio
less than one indicates the opposite. The lower the ratio, the greater the contribution
of NCDs and injuries to a state’s overall disease burden. [6]
The Human Development Index (HDI) is a statistic composite index of life
expectancy, education, and per capita income indicators, which are used to rank
countries into four tiers of human development. A country scores a higher HDI when
the lifespan is higher, the education level is higher, and the gross national
income GNI (PPP) per capita is higher. It was developed by Indian
economist Amartya Sen and Pakistani economist Mahbub ul Haq and was further
used to measure a country's development by the United Nations Development
Programme (UNDP) HDI measures as
• A long and healthy life: Life expectancy at birth
• Education index: Mean years of schooling and Expected years of schooling
• A decent standard of living: Gross National Income (GNI) per capita Purchasing
Power Parity (PPP international dollars) [7]
In its 2010 Human Development Report, the UNDP began using a new method of
calculating the HDI. The following three indices are used:
1. Life Expectancy Index LEI = (LE - 20) / (85-20), LE is life expectancy
LEI is 1 when Life expectancy at birth is 85 and 0 when Life expectancy at
birth is 20.

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2. Education Index, EI = (MYSI + EYSI)/2
where
o MYSI = MYS/15, where MYSI is the mean years of schooling index
Fifteen is the projected maximum of this indicator for 2025.
o EYSI = EYS/18, where EYSI is the expected years of schooling index
Eighteen is equivalent to achieving a master's degree in most countries.
3. INCOME INDEX, II =
[ln (GNI per capita) - ln(100)]/[ln(75,000) - ln(100)]
II is 1 when GNI per capita is $75,000 and 0 when GNI per capita is
$100.
The geometric means of these components equals the
HDI = [LEI * HI * II]^(1/3) [7]
India's ranking in the human development index (HDI) improved marginally by a
notch to 129 in 2018, showed a report released by the United Nations Development
Program (UNDP). The report also found that despite progress, group-based
inequalities persist in India, especially acting women and girls. According to the
report, more Indians were showing biases in gender social norms, indicating a
backlash to women’s empowerment. The overall index, given in the 2019 HDI
report of UNDP, showed that India scored 0.647 in 2019, as against 0.643 in the
previous year 2018. Over the years, India’s HDI rank has improved steadily due to
reduction in absolute poverty, along with gains in life expectancy, education, and
access to health care. [8] in low- and middle-income countries, an increasing number
of studies show associations between NCDs and certain social determinants,
particularly education and income levels. [9]

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Rational of Study
With almost one-fifth of the world’s population living in India, the health status and
the drivers of health loss are expected to vary between different parts of the country
and between the states. In 2016, 55% of the total disease burden in India was caused
by NCDs, 33% by CMNNDs, and 12% by injuries. The burden of CMNNDs has
decreased and that of NCDs increased across all states in India from 1990 to 2016.
However, there are wide variations between the states, with the contribution of
NCDs to the total disease burden ranging from 48% to 75%, CMNNDs ranging from
14% to 43%, and injuries ranging from 9% to 14% across the states in 2016. Even
with a decreasing burden of CMNNDs, it is important to note that for diarrhoeal
diseases, iron-deficiency anemia, and tuberculosis, the DALY rates are higher than
would be expected in most states for their development level (Socio-demographic
Index). The per capita health loss from the individual diseases varies widely between
states, with a range of over five-fold for five of the 10 leading individual causes, i.e.,
ischemic heart disease, diarrhoeal diseases, lower respiratory infections, stroke, and
tuberculosis. [9]. Due to the chronic nature of the disease and technological
advancements in care, cost of treatment are high which either leads to barriers to
access, or catastrophic expenditures for those who undergo treatment. [10].
Most of the estimates suggest that the NCDs in India account for an economic
burden in the range of 5–10% of GDP which is significant. While government
expenditure in advanced economies is on average 45% of GDP, the average is less
than 24% in low-income countries. Out-of-pocket payments are the single largest
component of domestic health funding in many developing countries, accounting
for 48% and 36% of total health expenditure in low- and middle-income countries
respectively in 2012. The negative effects of out-of-pocket payments have been well
established. Out-of-pocket payments for NCD services impose a particularly heavy
financial burden on households, given the long-term nature of NCDs and the
frequently high costs associated with diagnosing and treating NCDs. [11].

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More recently, the NITI Aayog (National Institution for Transforming India) has
been tasked with implementing programs in response to the United Nations
Sustainable Development Goals Agenda, which includes the target of reducing
preventable NCD deaths by a third by 2030.
The Ayushman Bharat Yojana, or National Health Protection Scheme, aims to create
health and wellness centres to provide primary healthcare and provide insurance
coverage of up to ₹500,000 (~US$8000) to a family per year. The scheme currently
covers in-hospital secondary and tertiary care, but mechanisms to pay for the chronic
outpatient care and medication costs, the major drivers of NCD-related OOPE
remain unclear. [12] with a view to attaining national NCD targets for 2025 and 2030,
based on the nine global, voluntary targets for NCDs and the NCD-related targets
included in the Sustainable Developmental Goals-3. [13].
NCDs kill approximately 41 million people (71% of global deaths) worldwide each
year, including 14 million people who die too young between the ages of 30 and 70.
The majority of premature NCD deaths are preventable. According to World Health
Organization (WHO) projections, the total annual number of deaths from NCDs will
increase to 55 million by 2030, if timely interventions are not done for prevention
and control of NCDs. In India, nearly 5.8 million people (WHO report, 2015) die
from NCDs (heart and lung diseases, stroke, cancer and diabetes) every year or in
other words 1 in 4 Indians has a risk of dying from an NCD before they reach the
age of 70. [14].
India like most rapidly growing economies is facing a looming epidemic of
noncommunicable diseases (NCDs). Market forces promote junk foods, sugar
sweetened beverages (SSBs), tobacco, and alcohol. Increasing automobiles on the
roads lead to air pollution. Changing work environments with long hours in front of
computers lead to a sedentary lifestyle. While unhealthy diet, tobacco, alcohol, and
sedentary lifestyle are known determinants of NCDs [15].

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India is one of the first countries to respond to these challenges and set specific
targets and indicators to bring down the burden of NCDs mortality by 25% by the
year 2025—the so-called 25 × 25 target. [16]
The majority of NCD deaths occur in low and middle-income countries such as
India, which is undergoing an epidemiological health transition owing to rapid
urbanization, which in turn has led to an overall economic rise, but with certain
associated flipsides (risk factors) [17]
India being a populous country of about 1.3 billion, contributes to more than 2/3rd
of the total deaths due to NCDs in the South-East Asia Region (SEAR) of WHO
(WHO, 2014; United Nations Statistics Division). As per the 2011 report on NCD
status in SEAR, raised BP, raised blood glucose and tobacco use were the three
major risk factors responsible for majority of deaths annually in this region. [18]
There are recognizable interconnections between health, particularly NCDs, and
sustainable development. Effectively and sustainably addressing the health and
developmental threat of NCDs requires careful attention to underlying social,
cultural, economic, political, and environmental determinants that operate at societal
level and in turn influence the behavioural risk factors. Vulnerable and socially
disadvantaged populations face disproportionate risk and poor health outcome from
NCDs. The actions to tackle these social determinants extend beyond the direct
influence of the health sector and health policies. Thus, public policies and decisions
made in all sectors and at different levels of governance can have a significant
impact on population health and health equity. [19]
Besides social determinants, the growing burden of NCDs is accelerated by the
negative effects of globalization, rapid and unplanned urbanization and increasingly
sedentary lives. It is recognized that effective NCDs prevention and control require
leadership, coordinated multi-stakeholder engagement and multisectoral action for
health both at government level and at the level of a wide range of actors. Health-

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in-all-policies and whole-of-government approaches require engagement across
sectors such as health, agriculture, communication, education, employment, energy,
environment, finance, food, foreign affairs, housing, justice and security, legislature,
social welfare, sports, tax and revenue, trade and industry, transport, urban planning
and youth affairs. [20]

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Review of Literature
During the last century, Kerala witnessed a drastic decline in mortality and
consequent expansion in life expectancy. This achievement is comparable with
many developed countries. This change in Kerala was a result of superior medical
care through primary health institutions and provision of water and sanitary
facilities, which were mainly done after the formation of state in 1956 [21]
Mortality reduction in the state was the result of social improvement especially
through education climatic conditions and scattered pattern of settlements, and
mysterious disappearance of the major causes of death, like plague [22]
The epidemiological profile of low- and middle-income countries reflects the
diseases of adults rather than childhood while retaining high exposure to risk factors
associated with infectious diseases, leaving poor rural areas and urban slums with
persisting high rates of infections and childhood deaths alongside richer urban areas
where adults die prematurely of noncommunicable diseases [23]
Like other developing countries, India is undergoing rapid epidemiological
transition and change in the mortality pattern as a result of its socioeconomic and
demographic changes [24]
The rate of deaths resulting from noncommunicable diseases was around 200 per
hundred thousand populations in 1990, but it increased to 250 per hundred thousand
populations by 2006, thus recording a 25% increase in death rate due to
noncommunicable diseases. deaths due to noncommunicable diseases will increase
during 2006 to 2020 (from 243 per 100000 in 2006 to 290 per 100000 in (2020)
which countsfor20%rise from initial levels. [25]
Globally, the prevalence of DM ranged between 4% and12% in 2013, with the
highest prevalence in Middle-East and Northern African (> 12%) and the lowest in
Sub-Saharan countries (< 4%). The prevalence of DM was high in older age groups

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in both low-to middle, and high-income regions. The impact of human development
on individual health: a causal mediation analysis examining pathways through
education and body mass index impact of national human development on
individual health and possible pathways via education and BMI, using large
population data. The HDI effect on individual-level health was mainly through
pathways other than education and BMI. The impact of HDI on health was greater
for females than for males. [26]
By sex and residence, the prevalence rate of chronic diseases was highest among
urban males and was characterized by a high prevalence among old–old and oldest
of old (ages 80 and above). Among young–old (ages 60–69), the prevalence rate was
relatively low compared to old–old and oldest of old. [27]
In UAE Maximum patient are suffering to cardiovascular diseases (CVD), which
include stroke, angina, coronary artery diseases, and so on followed by respiratory
diseases. Among urban subjects, maximum number of patients had a complaint of
CVD followed by respiratory diseases while diabetes and cancer had been reported
less as compare to other NCDs [28]
Mental health had only recently been included by the WHO as a NCD. The
worsening burden of NCDs in the LMICs often comes accompanied by other factors
straining health of the public. Results from Bangladesh data shows that during 1986–
2006, deaths from NCDs increased from 8% to 68% in a rural area The decreasing
trend of CVD in USA since 1980 is a testament to the fact that even increasing trend
of NCDs as insurmountable as they are can be reversed. The three levels of causes
for NCDs include underlying drivers, behavioural risk factors and metabolic,
physiological risk factors. [29]
The interwoven nature of NCDs and sustainable human development has
implications for social, economic and environmental development. The rapidly
increasing levels of CO2 emissions around the globe need to be addressed. The big
effects on health in the future would come from malnutrition, extreme weather

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events (flooding and droughts), water shortages, mass migration and wars over
resources. Policies that address climate change (less pollution, motorized transport,
and meat production) are good for NCDs and vice versa. [30]

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Objectives
General Objective –
To analyze the correlation between Human development Indices and
Epidemiological transition Ratio among Indian state.
Specific Objectives –
1. To review the epidemiological transition ratio and respective human
development indices of Indian states
2. To prove the hypothesis between human development Indices and
Epidemiological transition ratio of Indian states.

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Methodology
Study based on Secondary sources of data. The human development index data taken
from United national development program (UNDP) HDI -India 2019 and
epidemiological transition ratio (ETR)status of India states taken from -Indian
Council of Medical Research study -India states disease burden 2017) used for
analysis.
Research Design – Correlation nonexperimental study
Variables- Human development index and (HDI) and epidemiological transition
ratio (ETR)
Include- All Indian states and Delhi
Exclude- All Union Territory as per Indian administrative division 2017
Data Analysis Method - Spearman Rank Order correlation coefficient.
Values always range between
-1 (strong negative relationship)
+1 (strong positive relationship).
Values at or close to zero imply weak or no linear relationship.

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Data Analysis Method Spearman Rank Order correlation coefficient.
S.no States HDI= X Rank X ETR =Y Rank Y D d2
1 Kerala 0.779 1 0.16 1 0 0
2 Goa 0.761 2 0.21 2 0 0
3 New Delhi 0.746 3 0.38 11.5 -8.5 72.25
4
Himachal
Pradesh 0.725 4 0.30 5 -1 1
5 Punjab 0.723 5 0.29 4 1 1
6 Sikkim 0.716 6 0.45 15.5 -9.5 90.25
7 Haryana 0.708 7.5 0.40 13 -5.5 30.25
8 Tamil Nadu 0.708 7.5 0.26 3 4.5 20.25
9 Mizoram 0.705 9 0.53 20 -11 121
10 Maharashtra 0.696 10.5 0.33 6.5 4 16
11 Manipur 0.696 10.5 0.42 14 -3.5 12.25
12
Jammu and
Kashmir 0.688 12 0.34 8.5 3.5 12.25
13 Uttarankhand 0.684 13 0.46 17.5 -4.5 20.25
14 Karnataka 0.682 14 0.34 8.5 5.5 30.25
15 Nagaland 0.679 15 0.47 19 -4 16
16 Gujarat 0.672 16 0.46 17.5 -1.5 2.25
17 Telangana 0.669 17 0.38 11.5 5.5 30.25
18
Arunachal
Pradesh 0.660 18 0.55 21 -3 9
19 Tripura 0.658 19 0.45 15.5 3.5 12.25
20 Meghalaya 0.656 20 0.64 26 -6 36
21
Andhra
Pradesh 0.650 21 0.37 10 11 121
22 West Bengal 0.641 22 0.33 6.5 15.5 240.25
23 Rajasthan 0.629 23 0.66 27 -4 16
24 Assam 0.614 24 0.62 25 -1 1
25 Chhattisgarh 0.613 25 0.60 23.5 1.5 2.25
26
Madhya
Pradesh 0.606 26 0.60 23.5 2.5 6.25
27 Orissa 0.606 26 0.58 22 4 16
28 Jharkhand 0.599 28 0.69 29 -1 1
29 Uttar Pradesh 0.596 29 0.68 28 1 1
30 Bihar 0.576 30 0.74 30 0 0
∑ d2
=937.5

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Result Details
X Rank Mean Rank: 15.5 Standard Deviation 8.8
Y Rank Mean Rank: 15.5 Standard Deviation 8.8
1-(6×937.5)/30(900-1)
1-5625/26970
1-0.208=0.792
By normal standard the association between the human development indices and
Epidemiological ratio has been considered statistically significant
This indicates a positive relationship between the Human development indices
(improvement in Education, Income and Health) and Epidemiological transition
ratio (Non-Communicable Disease +Injury)
1 2
11.5
5 4
15.5
13
3
20
6.5
14
8.5
17.5
8.5
19
17.5
11.5
21
15.5
26
10
6.5
27
25
23.523.5
22
29 28
30
y = 0.7938x + 3.2228
R² = 0.6245
0
5
10
15
20
25
30
35
0 5 10 15 20 25 30 35
ETR

19. 18 | P a g e
Results
There appears to be a Positive correlation value (0.78). There is a 0.1% probability
that your null hypothesis is correct p=0.001 (99.9% statistical significance level).
According the result accept the alternate hypothesis (that there is a positive
correlation between Human Development Indices and Epidemiological Transitions)
The state Kerala (HDI rank-1 and ETR Rank 1), Goa(HDI rank-2 and ETR Rank 2)
Himachal Pradesh(HDI rank-5 and ETR Rank 4) and Punjab (HDI rank-5 and ETR
Rank 4) have linear relationship between HDI and ETR (High rank in HDI and
ETR).
The bottom rank states Bihar (HDI rank-30 and ETR Rank 30), Uttar Pradesh (HDI
rank-29 and ETR Rank 28), Jharkhand (HDI rank-28 and ETR Rank 29), Assam
(HDI rank-24 and ETR Rank 25), Chhattisgarh(HDI rank-25 and ETR Rank 23.5)
and Madhya Pradesh(HDI rank-26 and ETR Rank 23.5) have also linear relationship
(Low rank HDI to respective ETR)
The States Delhi (HDI rank-3 and ETR Rank 11.5), Haryana (HDI rank-7.5 and
ETR Rank 13) , Sikkim (HDI rank-6 and ETR Rank 15.5) and Mizoram (HDI rank-
9 and ETR Rank 20) does not have Linear relationship (Have High HDI but Low
rank in ETR)
vice versa Andhra Pradesh (HDI rank-21 and ETR Rank 10) and West Bengal (HDI
rank-22 and ETR Rank 6.5) have Low rank in HDI respective to their ETR. Rest of
state have moderate relationship to HDI and ETR.

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Discussion
These findings highlight the fact that India’s states will require very different policy
approaches according to the nature of the disease burden they are facing. The rest of
this report takes a deeper look into the diseases and injuries that are driving these
trends across the states.
The wide variations between the states in this epidemiological transition are
reflected in the range of the contribution of major disease groups to the total disease
burden in 2016: 48% to 75% for non-communicable diseases, 14% to 43% for
infectious and associated diseases, and 9% to 14% for injuries. Kerala, Goa, and
Tamil Nadu have the largest dominance of non-communicable diseases and injuries
over infectious and associated diseases, whereas this dominance is present but
relatively the lowest in Bihar, Jharkhand, Uttar Pradesh, and Rajasthan.
However, the magnitude and causes of disease burden and the risk factors vary
greatly between the states. The change to dominance of NCDs and injuries over
CMNNDs occurred about a quarter century apart in the four ETL state groups.
Nevertheless, the burden of some of the leading CMNNDs continues to be very high,
especially in the lowest ETL states. This comprehensive mapping of inequalities in
disease burden and its causes across the states of India can be a crucial input for
more specific health planning for each state.
The major risk factors for NCDs, including high systolic blood pressure, high fasting
plasma glucose, high total cholesterol, and high body-mass index, increased from
1990 to 2016, with generally higher levels in higher ETL states; ambient air
pollution also increased and was highest in the low ETL group. The incidence rate
of the leading causes of injuries also increased from 1990 to 2016. The five leading
individual causes of DALYs in India in 2016 were ischemic heart disease, chronic
obstructive pulmonary disease, diarrheal diseases, lower respiratory infections, and
cerebrovascular disease; and the five leading risk factors for DALYs in 2016 were

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child and maternal malnutrition, air pollution, dietary risks, high systolic blood
pressure, and high fasting plasma glucose. Behind these broad trends many
variations existed between the ETL state groups and between states within the ETL
groups. Of the ten leading causes of disease burden in India in 2016, five causes had
at least a five-time difference between the highest and lowest state-specific DALY
rates for individual causes.
Health status improving, but major inequalities between states
Life expectancy at birth improved in India from 59.7 years in 1990 to 70.3 years in
2016 for females, and from 58.3 years to 66.9 years for males. There were, however,
continuing inequalities between states, with a range of 66.8 years in Uttar Pradesh
to 78.7 years in Kerala for females, and from 63.6 years in Assam to 73.8 years in
Kerala for males in 2016. The per person disease burden measured as DALYs rate
dropped by 36% from 1990 to 2016 in India, after adjusting for the changes in the
population age structure during this period. But there was an almost two-fold
difference in this disease burden rate between the states in 2016, with Assam, Uttar
Pradesh, and Chhattisgarh having the highest rates, and Kerala and Goa the lowest
rates. While the disease burden rate in India has improved since 1990, it was 72%
higher per person than in Sri Lanka or China in 2016. The under-5 mortality rate has
reduced substantially from 1990 in all states, but there was a four-fold difference in
this rate between the highest in Assam and Uttar Pradesh as
compared with the lowest in Kerala in 2016, highlighting the vast health inequalities
between the states.
Large differences between states in the changing disease profile
Of the total disease burden in India measured as DALYs, 61% was due to
communicable, maternal, neonatal, and nutritional diseases (termed infectious and
associated diseases in this summary for simplicity) in 1990, which dropped to 33%
in 2016. There was a corresponding increase in the contribution of non-
communicable diseases from 30% of the total disease burden in 1990 to 55% in

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2016, and of injuries from 9% to 12%. Infectious and associated diseases made up
the majority of disease burden in most of the states in 1990, but this was less than
half in all states in 2016. However, the year when infectious and associated diseases
transitioned to less than half of the total disease burden ranged from 1986 to 2010
for the various state groups in different stages of this transition. The wide variations
between the states in this epidemiological transition are reflected in the range of the
contribution of major disease groups to the total disease burden in 2016: 48% to
75% for non-communicable diseases, 14% to 43% for infectious and associated
diseases, and 9% to 14% for injuries. Kerala, Goa, and Tamil Nadu have the largest
dominance of non-communicable diseases and injuries over infectious and
associated diseases, whereas this dominance is present but relatively the lowest in
Bihar, Jharkhand, Uttar Pradesh, and Rajasthan.
Infectious and associated diseases reducing, but still high in many states
The burden of most infectious and associated diseases reduced in India from 1990
to 2016, but five of the ten individual leading causes of disease burden in India in
2016 still belonged to this group: diarrhoeal diseases, lower respiratory infections,
iron-deficiency anaemia, preterm birth complications, and tuberculosis. The burden
caused by these conditions generally continues to be much higher in the Empowered
Action Group (EAG) and North-East state groups than in the other states, but there
were notable variations between the states within these groups as well. The range of
disease burden or DALY rate among the states of India was 9 fold for diarrhoeal
disease, 7 fold for lower respiratory infections, and 9 fold for tuberculosis in 2016,
highlighting the need for targeted efforts based on the specific trends in each state.
The burden also differed between the sexes, with diarrhoeal disease, iron-deficiency
anaemia, and lower respiratory infections higher among females, and tuberculosis
higher among males. The proportion of total disease burden caused by infectious
and associated diseases was highest among children, which contributed to the
disproportionately higher overall disease burden suffered by the under-5 years age

23. 22 | P a g e
group. For India as whole, the disease burden or DALY rate for diarrhoeal diseases,
iron-deficiency anaemia, and tuberculosis was 2.5 to 3.5 times higher than the
average globally for other geographies at a similar level of development, indicating
that this burden can be brought down substantially.
Rising burden of non-communicable diseases in all states
The contribution of most of the major non-communicable disease groups to the total
disease burden has increased all over India since 1990, including cardiovascular
diseases, diabetes, chronic respiratory diseases, mental health and neurological
disorders, cancers, musculoskeletal disorders, and chronic kidney disease. Among
the leading non-communicable diseases, the largest disease burden or DALY rate
increase from 1990 to 2016 was observed for diabetes, at 80%, and ischaemic heart
disease, at 34%. In 2016, three of the five leading individual causes of disease
burden in India were non-communicable, with ischaemic heart disease and chronic
obstructive pulmonary disease as the top two causes and stroke as the fifth leading
cause. The range of disease burden or DALY rate among the states in 2016 was 9-
fold for ischaemic heart disease, 4-fold for chronic obstructive pulmonary disease,
and 6-fold for stroke, and 4- fold for diabetes across India. While ischaemic heart
disease and diabetes generally had higher DALY rates in states that are at a more
advanced epidemiological transition stage toward non-communicable diseases, the
DALY rates of chronic obstructive pulmonary disease were generally higher in the
EAG states that are at a relatively less advanced epidemiological transition stage.
On the other hand, the DALY rates of stroke varied across the states without any
consistent pattern in relation to the stage of epidemiological transition. This variety
of trends of the different major non-communicable diseases indicates that policy and
health system interventions to tackle their increasing burden have to be informed by
the specific trends in each state.

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Increasing but variable burden of injuries among states
The contribution of injuries to the total disease burden has increased in most states
since 1990. The highest proportion of disease burden due to injuries is in young
adults. Road injuries and self-harm, which includes suicides and non-fatal outcomes
of self-harm, are the leading contributors to the injury burden in India. The range of
disease burden or DALY rate varied 3-fold for road injuries and 6 fold for self-harm
among the states of India in 2016. There was no consistent relationship between the
DALY rates of road injuries or self-harm versus the stage of epidemiological
transition of the states. The burden due to road injuries was much higher in males
than in females. The DALY rate for self-harm for India was 1.8 times higher than
the average globally for other geographies at a similar level of development in 2016.
India: Health of the Nation’s States 19
Unacceptably high risk of child and maternal malnutrition
While the disease burden due to child and maternal malnutrition has dropped in India
substantially since 1990, this is still the single largest risk factor, responsible for
15% of the total disease burden in India in 2016. This burden is highest in the major
EAG states and Assam and is higher in females than in males. Child and maternal
malnutrition contribute to disease burden mainly through increasing the risk of
neonatal disorders, nutritional deficiencies, diarrhoeal diseases, lower respiratory
infections, and other common infections. As a stark contrast, the disease burden due
to child and maternal malnutrition in India was 12 times higher per person than in
China in 2016. Kerala had the lowest burden due to this risk among the Indian states,
but even this was 2.7 times higher per person than in China. This situation after
decades of nutritional interventions in the country must be rectified as one of the
highest priorities for health improvement in India.

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Rising risks for cardiovascular diseases and diabetes
Of the total disease burden in India in 1990, a tenth was caused by a group of risks
including unhealthy diet, high blood pressure, high blood sugar, high cholesterol,
and overweight, which mainly contribute to ischaemic heart disease, stroke, and
diabetes. The contribution of this group of risks increased massively to a quarter of
the total disease burden in India in 2016. The combination of these risks was highest
in Punjab, Tamil Nadu, Kerala, Andhra Pradesh, and Maharashtra in 2016, but
importantly, the contribution of these risks has increased in every state of the country
since 1990. The other significant contributor to cardiovascular diseases and diabetes,
as well as to cancers and some other diseases, is tobacco use, which was responsible
for 6% of the total disease burden in India in 2016. All of these risks are generally
higher in males than in females. The sweeping increase of the burden due to this
combination of risks in every part of the country indicates emphatically that major
efforts need to be put in place to control their impact in every state before the
situation gets totally out of control.
Importance of understanding the specific health situation of each state
Understanding the health and disease trends in groups of states at a similar level of
development or epidemiological transition is an important intermediate step in
teasing apart the heterogeneity of disease and risk factor epidemiology in India.
However, effective action to improve health must finally be based on the specific
health situation of each state. This point is elucidated by significant variations in the
burden from leading diseases and risk factors in 2016 between the following pairs
of states that have physical proximity and are at similar levels of development and
epidemiological transition. The major EAG states of Madhya Pradesh and Uttar
Pradesh both have a relatively lower level of development indicators and are at a
similar less advanced epidemiological transition stage. However, Uttar Pradesh had
50% higher disease burden per person from chronic obstructive pulmonary disease,
54% higher burden from tuberculosis, and 30% higher burden from diarrhoeal
diseases, whereas Madhya Pradesh had 76% higher disease burden per person from

26. 25 | P a g e
stroke. The cardiovascular risks were generally higher in Madhya Pradesh, and the
unsafe water and sanitation risk was relatively higher in Uttar Pradesh. The two
North-East India states of Manipur and Tripura are both at a lower-middle stage of
epidemiological transition but have quite different disease burden rates from specific
leading diseases. Tripura had 49% higher per person burden from ischaemic heart
disease, 52% higher from stroke, 64% higher from chronic obstructive pulmonary
disease, 159% higher from iron-deficiency anaemia, 59% higher from lower
respiratory infections, and 56% higher from neonatal disorders. Manipur, on the
other hand, had 88% higher per person burden from tuberculosis and 38% higher
from road injuries. Regarding the level of risks, child and maternal malnutrition, air
pollution, and several of the cardiovascular risks were higher in Tripura. The two
adjoining north Indian states of Himachal Pradesh and Punjab both have a relatively
higher level of development indicators and are at a similar more advanced
epidemiological transition stage. However, there were striking differences between
them in the level of burden from specific leading diseases. Punjab had 157% higher
per person burden from diabetes, 134% higher burden from ischaemic heart disease,
49% higher burden from stroke, and 56% higher burden from road injuries. On the
other hand, Himachal Pradesh had 63% higher per person burden from chronic
obstructive pulmonary disease. Consistent with these findings, Punjab had
substantially higher levels of cardiovascular risks than Himachal Pradesh. These
examples highlight why it is necessary to understand the specific disease burden
trends in each state, over and above the useful broad insights provided by trends
common for groups of states at similar levels of epidemiological transition, if health
action has to be planned for the specific context of each state. The chances of
achieving the overall health targets set by India would be much higher if the biggest
health problems and risks in each state are tackled on priority than with a more
generic approach that does not take into account the specific disease burden trends
in each state.

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Suggestion
Between 1990 and 2018, India’s HDI value increased by 50 per cent (from 0.431 to
0.647), which places it above the average for countries in the medium human
development group (0.634) and above the average for other South Asian countries
(0.642). Through political declarations, heads of states and governments have
committed to reduce premature deaths by 30% before 2030. The steps should take
to combat to NCDs can be like
• A set of cost effective and affordable policy options (best buys) exist to tackle
NCDs
• Interventions to reduce risk from non-communicable diseases should be
applied through the life course.
• Actions targeted at one life stage often also influence health behavior and
outcomes at other stages
• The life course approach can help determine when and how to influence the
social determinants of health
• Strengthening health systems to address NCDs: There is need to scale up the
‘NCD Clinic’ model, a Government of India initiative and establish these
clinics at the primary healthcare level to promote integrated chronic disease
management. Training of healthcare workforce at primary, secondary and
tertiary levels would enhance capacity for integrated NCDs management. An
adequate logistics management system needs to be set up to procure and
supply equipment, vaccines, diagnostics and medicines required for NCDs.
Rapid referral systems need to be put in place for transporting patients with
medical emergencies like myocardial infarction, stroke and asthma and
complications like renal failure and retinopathy following NCDs. All these
require additional resources by the Governments without compromising on

28. 27 | P a g e
other priorities, notably, for prevention and control of communicable diseases
and improving reproductive and child health.
• Strategic information management system: There is need to establish Health
Information System for NCDs and establish a robust surveillance mechanism.
There should be development of common tools and protocols to conduct
uniform surveys across the country and assess changing trends of NCDs as
well as their risk factors. There is need for periodic independent evaluation to
assess effectiveness of strategies for prevention and control of NCDs.
• Healthcare financing: India should increase the percentage expenditure of
GDP on healthcare from the current 1.1% to at least 2.5% by 2025, with an
increased focus on preventing and treating NCDs. NCDs are chronic in nature
and may require life-long treatment. The option to devise innovative health
insurance schemes to provide healthcare coverage, particularly for people
below poverty line, can avert catastrophic economic implications on the
affected families.
• Public Private partnerships: India has a mixed healthcare system. There is
need to identify strategies to involve voluntary organizations and private
health care sector in the diagnosis and treatment of NCDs, emergency care,
training etc. There is need to formulate standard treatment guidelines and
implement them in public and private hospitals to maintain acceptable level
of quality and accountability in the provision of care.

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Conclusion
India is currently experiencing the double burden of communicable and non-
communicable diseases. In recent decades, the age pattern of morbidity has been
rising, primarily due to increased prevalence of chronic diseases, resulting in
significant structural changes in disease patterns. India is experiencing rapid health
transition, including increased life expectancy at old ages (e60 and above). However, the
older population is living in poor health. Comprehensive health interventions are
required for prevention and control of chronic diseases. However, the older
population is living in poor health. Comprehensive health interventions are required
for prevention and control of chronic diseases. In terms of mortality transition, In
terms of mortality transition, India lags behind developed nations. The combination
of a double burden of disease with high morbidity rates presents challenges for
improving the overall health status of the population and necessitates a
comprehensive policy and action to prevent and control this burden
The changing pattern of diseases observed over recent years, from acute infectious
and deficiency diseases to the chronic non-communicable diseases, is a continuous
process of transformation with some diseases disappearing and others appearing or
reappearing. Infectious diseases are still an important public health problem and a
major cause of death and of illness and will continue to be so for future generations.
At the same time, non-communicable diseases are coming to the forefront as causes
of illness and death, especially in countries where it used to be possible to control
many communicable diseases. This transition is very vulnerable as many biological,
environmental, social, cultural and behavioural factors have been responsible for
structuring these patterns in the community. It is subject to breaks in continuity,
slowdowns or even reversals of the transition. Several stages of transition may
overlap in the same country. This represents a challenge to national health.
Epidemiologic surveillance has a major role to play in identifying the chances and
in planning how to address them and should be given the attention it deserves. The

30. 29 | P a g e
public has a major role to play, and hence the necessity for public health education
and promotion of healthy lifestyles. Health education efforts to achieve positive
behavioural changes are essential for the prevention and control of diseases. A
carefully conceived media campaign can have a beneficial effect on changing
behaviours related to the occurrence of diseases, such as smoking, obesity, alcohol
consumption and other dangerous behaviour and promote healthy lifestyle.
Burden of NCDs and their risk factors should be viewed broadly for their impact on
life expectancy, quality of life, social and economic implications. India has to
achieve the Sustainable Development Goal-3 to ensure healthy lives and promote
well-being at all ages as well as Target 3.4 to reduce by one third the premature
mortality from non-communicable diseases through prevention and treatment and
promote mental health and well-being. The fraternity of Community Medicine needs
to rise to the occasion by contributing in a big way to prevent and control NCDs,
particularly in the areas of surveillance, capacity building, health promotion,
behavior change communication, public health management and operational
research for universal access, especially in the rural areas and urban poor
communities.

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References
1. Omran AR. The epidemiologic transition: a theory of the epidemiology of
population change. The Milbank Memorial Fund Quarterly. 1971;49(4):509–
38.
2. Rogers RG, Hackenberg R. Extending epidemiologic transition theory: a new
stage. Soc Biol. 1987;34(3–4):234.
3. lshansky SJ, Ault AB. The fourth stage of the epidemiologic transition: the
age of delayed degenerative diseases. The Milbank Memorial Fund Quarterl
4. http://www.emro.who.int/emhj-volume-2-1996/volume-2-issue-
1/article2.html
5. The Epidemiologic Transition: A Theory of the Epidemiology of Population
Change
6. India: Health of the Nation's States the India state Level Disease Burden
Initiatives ICMR/IHME/PHFI 2017
7. A. Stanton, Elizabeth (February 2007). "The Human Development Index: A
History". PERI Working Papers: 14–15. Archived from the original on 28
February 2019. Retrieved 28 February 2019
8. Ranked 129, India marginally improves in human development index in 2018
| Business Standard news
9. Bose ML Social and cultural history of ancient India. 2nd edn. International
Monetary Fund World economic outlook update.
10.Outcome document of the high-level meeting of the General Assembly on the
comprehensive review and assessment of the progress achieved in the
prevention and control of non-communicable diseases. United Nations
General Assembly, resolution 68/300, 10 July 2014.
11.Global Health Expenditure Database: http://who.int/health-accounts/ghe
12.Ministry of Health and Family welfare MoHFW India

32. 31 | P a g e
13.Addis Ababa Action Agenda, 2015; 2030 Agenda for Sustainable
Development; United Nations Political Declaration on NCDs; United Nations
Outcome Document on NCDs; Global Action Plan on NCDs:
14.https://www.nhp.gov.in/healthlyliving/ncd2019
15.Kontis V, Mathers CD, Bonita R, Stevens GA, Rehm J, Shield KD, et al.
Regional Contribution of Six Preventable Risk Factors to achieving the 25 ×
25 non-communicable disease mortality reduction targets: A modeling study.
Lancet Glob Health 2015;3:e746-57.
16.Chakma and Gupta, 2014 The majority of NCDs
17.World Health Organization. India: first to adapt the Global Monitoring
Framework on Non-Communicable Diseases (NCDs). January 2015.
Available at: http://www.who.int/features/2015/ncd-india/en/.
18.Discussion paper addressing the Social Determinants of Noncommunicable
Diseases; UNDP; 2013
19.Commission on Social Determinants of Health. Closing the gap in a
generation: health equity through action on the social determinants of health:
Commission on Social Determinants of Health final report, WHO; 2008
20.Global, regional, and national disability-adjusted life-years (DALYs) for 332
diseases and injuries and healthy life expectancy (HALE) for 195 countries
and territories, 1990–2016: a systematic analysis for the Global Burden of
Disease Study 2016. Lancet. 2017; 390: 1260-1344
21.(Parameswaran, 2000; Franke and Chasin, 2000; Parayil, 2000).
22.(Panikar and Soman 1984; Panikar, 1999).
23.Z. A. Karar, N. Alam, and P. Streatfield, “Epidemiological transition in rural
Bangladesh, 1986–2006,” Global Health Action, vol. 2,
24.S. Goli and P. Arokiasamy, “Trends in health and health inequalities among
major states of India: assessing progress through convergence models,”
Health Economics, Policy and Law, vol. 9, no. 2, pp. 143–168, 2014.

33. 32 | P a g e
25.Epidemiological Transition in Urban Population of Maharashtra RahulKoli,1,
SrinivasGoli,2andRiddhiDoshi IIPS Mumbai
26.Relation Between the Prevalence of Diabetes Mellitus and Human
Development Index: A Global Ecological Study Understanding
epidemiological transition in India
27.Suryakant Yadav and Perianayagam Arokiasamy International Institute for
Population Sciences, Mumbai, India
28.Erratic Behavioral Attitude Leads to Noncommunicable Diseases: A Cross-
Sectional Study
29.Burkart K, Khan MH, Krämer A, Breitner S, Schneider A, Endlicher WR.
Seasonal variations of all-cause and cause-specific mortality by age, gender,
and socioeconomic condition in urban and rural areas of Bangladesh. Int J
Equity [Google Scholar]
30.Non‐Communicable Diseases (NCDs) in developing countries: a symposium
report Tina Dannemann Purnat, Nguyen Thi Anh Phuong,