Through the early and mid-phase of India’s epidemiological transition, the age pattern of morbidity was overwhelmed with infectious diseases (1). In the recent two decades, the prevalence of non-communicable diseases has escalated immensely in India (2). India’s swift progress through demographic and epidemiological transition has resulted into a bigger challenge of dual burden of communicable and non-communicable diseases (3, 4). With the share of older cohorts increasing relative to that of younger cohorts, infectious and nutritional disorders are being replaced by chronic, degenerative, and mental illnesses as the leading causes of morbidity and mortality (5, 6). The resulting concern is not just epidemiological but also economic. Non-communicable diseases, which could cause long-standing disabilities, have direct economic consequences at households and community level, both through the expenses on health care, which divert other expenditure, and also on levels of income through reduced labor productivity (7, 8).

Expenditure on health is highly lopsided across the globe, where the developed countries spend the most on health per person (9). The Organisation for Economic Co-operation and Development (OECD) countries accounted for less than 20% of the world’s population but were responsible for almost 90% of the world’s health spending (10). Health expenditure, both in terms of percentage of gross domestic product (GDP) spent on health and per capita health expenditure, is much higher in the developed countries than developing countries. Unlike in economic history of Colonial Age, in recent decades, global share of health spending is undergoing gradual but constant change in favor of developing Third World nations (11). Such inevitable and deep changes are led by top BRICS¹ emerging markets (12). In contrast, the ratio of public to private health expenditure is extremely low in India. Further, all the private expenditure in India (as in some other countries) almost exclusively represent household’s out-of-pocket health expenses. According to World Health Organization (WHO) (13), private share on total health-care spending in India is as high as 70%, only next to some poor African countries. In India, 86% of all private expenditure and 72% of total expenditure are out-of-pocket. These high out-of-pocket spending on health often takes a higher toll on the poor than the rich (14). Poor people in India spend about 15% of their monthly household income for medical treatment (15).

South Asian countries are going through a rapid demographic transition, which is often accompanied by epidemiological transition. In this phase, while communicable diseases are still pandemic, non-communicable diseases, such as cardiovascular disease, diabetes, respiratory diseases, and cancer, are picking pace. Ghaffar et al. (16) pointed out the growing risk of these diseases among South Asian population. The non-communicable disease in this region has some special feature in addition to those commonly available in the developing countries. The metabolic syndrome is very common among urban Indians (17, 18). The high prevalence of glucose intolerance and the distinctive dyslipidaemic pattern of reduced concentrations of high density lipoprotein (HDL) cholesterol and high concentrations of triglycerides characterize the metabolic profile, and abdominal obesity characterizes the phenotype of the urban adult in India. Impaired maternal and fetal nutrition, resulting into low birth weight poses a greater risk of cardiovascular disease in South Asia. While use of tobacco products increases the risk of cancer in the region, indoor air pollution mostly due to burning wood fuel contributes to chronic obstructive airway disease (16). Barik et al. (19), in their very recent article, has argued that richer Indian adults are at greater risk of developing non-communicable diseases such as diabetes, heart disease, and high blood pressure than their poorer counterparts. The report of the Global Burden of Disease reported that the share of non-communicable disease on the disease burden has increased from 31% in 1990 to 45% in 2010 (20).

Following the demographic transition, developed western countries have witnessed an epidemiological transition where the share of non-communicable diseases increased in the total disease burden. The non-communicable diseases require a very different health set up than which is required for communicable diseases. In the present paper, we have tried to project the future health scenario of India in the wake of demographic transition and associated health transition. We have estimated the likely scenario of share of communicable and non-communicable diseases among Indians and required economic resource for treatment of these maladies. Various countries have developed their National Health Accounts (NHA) estimates to plan their health budget according to the nature of diseases. India does not have such a comprehensive NHA estimate. This present study may throw some light to plan health budget according to the need of the hour and also for future.

We have used the Morbidity and Health care Survey (2004) 60th round, carried out by the National Sample Survey Organization (NSSO) under the Ministry of Statistics and Programme Implementation, Government of India as the main data source for the analysis. The survey was canvassed between January to June, 2004 across the whole of the Indian Union except (i) Leh (Ladakh) and Kargil districts of Jammu and Kashmir, (ii) interior villages of Nagaland situated beyond 5 km of the bus route, and (iii) villages in Andaman and Nicobar Islands which remain inaccessible throughout the year. It covered 73,868 households of which 47,302 were from rural areas and 26,566 from urban areas. Prevalence of various morbidities and utilization of health-care services from public and private sources, together with the expenditure incurred by the households in this process, have been collected through this survey. The survey collected information if a person was ailing during the last 15 days prior to the date of survey. The individual sample size was 383,338; of which 195,712 were males and 187,626 females.

The data collected can be summarized in three categories:

The first category comprises the inpatient health care received by the household members as hospitalized cases during last 365 days. The expenses incurred during the reference period for treatment (as an inpatient of a hospital) of such ailments and details of the health-care finance have been recorded here.

The classification of communicable and non-communicable diseases followed the classification adopted by WHO in Global Burden of Disease Studies, 2004 (Table A1 in Appendix). The prevalence of any ailment or morbidity has been defined as the number of persons ailing within the reference period per 1,000 persons exposed to the risk of the ailment from the same group of population.

The expected change in the share of each category of morbidities has been estimated up to year 2051. The main assumption behind this projection was that the prevalence rate of each morbidity category would remain unchanged among all the age groups over time. This is a very strong assumption, but we did not have a dataset which allows us to examine disease progression in Indian context. However, this demographic projection would help us to foresee the future of Indian epidemiology in the course of demographic transition, the process already started. Utilization of hospitalization services over the 15-day reference period was multiplied by 24.33 (i.e., 365/15) to obtain an annualized counterpart of hospitalizations (after netting out any hospitalizations reported in the 15-day reference period).

The yearly cost of treatment for communicable and non-communicable diseases has been estimated based on per unit cost of treatment for inpatient and outpatient, derived from the NSSO unit-level data. Age-specific hospital days have been estimated for each disease type. The average cost of treatment per stay as an inpatient and average duration of stay were estimated for each disease type to obtain per day average cost of treatment as inpatients, and multiplying it with the estimated hospital days provides the annual cost of treatment as an inpatient. The annual out-of-pocket expenditure as outpatient has also been estimated following the similar procedure, where out-of-pocket expenditure implies to the expenditure a household bears after deducting the reimbursement from various health-care financing sources. We reached the annual cost of treatment as an outpatient by multiplying the average cost of treatment with total number of outpatient visit. Age-specific inpatient and outpatient visit has been assumed to capture the effect of the increasing prevalence of non-communicable diseases beyond age 30 years.

Household level out-of-pocket expenses are the major source of health-care finance in India. Since the presence of health insurance in India is yet to feel, the rest of the health expenditure are met by the government via its provision of free or subsidized public facilities (21). Thus, we will focus primarily on only these two sources of health-care financing, referring to other funding sources when appropriate. Public subsidies for health have been estimated as the difference between total expenditure incurred on private facilities compared to public facilities. The entire analysis has been carried out using appropriate sample weight available in the dataset. SPSS 18 PASW software was used to analyze the data.

The study provides some insights into the upcoming health requirements in Indian health system. The age profile of the morbidity indicates a rising risk of non-communicable diseases as the population ages through demographic transition (2, 16, 25, 26). In spite of a higher cost of treatment, people prefer to visit private facilities than the public. In India, the private facilities are vast and diverse – ranging from a person from local medical shop to a super specialty hospital catering to medical tourists from abroad (27). These facilities are available even in small remote places and offers services as per the convenience of people. The cost of treatment in these private facilities also varies to a great extent. People frequently prefer to go to a nearby private facility for short term diseases, which requires outpatient visit. Choice among various private health practitioners arises when the disease is more severe and requires long-term care.

Though government provides subsidized services for public health facilities, people utilize these facilities mainly for inpatient care. The lower level government facilities such as the sub-centers and the primary health centers are not well equipped to serve for severe illnesses. The higher level and specialized government health facilities are often concentrated in urban places, and travel to these places requires higher level resources and often associated with wage loss (27). India, in the past decade, has introduced the Rashtriya Swasthya Bima Yojana, a health insurance scheme to cover the inpatient care expenses of the poor. It has also invested on the National Rural Health Mission in 2005, which provides budget support to expand and improve free primary care in public clinics. While these initiatives ensure government’s continued effort to improve health-care services and protect the poor from health related expenses, these barely promise on the step toward combating non-communicable disease risks.

The non-communicable diseases require attention at a very early stage and once developed, medication continues throughout lifetime. Neglecting these diseases incapacitates a person and may be even life threatening. Ghaffar et al. (16) attributed the environmental factors as the major determinants of these health conditions, whereas they noted sedentary life style, extreme poverty, and inadequate health system as the obstacle to tackle the challenge of non-communicable diseases in South Asia.

If India wishes to reap the demographic dividend out of its favorable age-structural transition, it needs to focus on the health of the youth. Creating an enabling atmosphere for the youth to lead a healthy life style, create awareness about the ill health effects of smoking and drinking, regular health check-ups, and good dietary intake, are the some among the possible ways to avoid health risks from non-communicable diseases. In a nutshell, investing on youth health may result into a higher return in future.

We acknowledge the possible various limitation of the study. The main limitation stands as the prevalence of morbidity is based on the reported ailments, which is subject to the knowledge and awareness of a particular morbidity and may differ from estimate-based clinical data. The study produces the shift in disease share on the basis of pure demographic profile, which certainly sets a basic level of alarm to Indian health system, but inadequate in long run. A longitudinal study with clinical investigation will help a more detailed projection. However, we have tried to pinpoint the short fall of the Indian health system to tackle the future health problem, which will come along with the ongoing demographic transition.

Both the authors have made significant contributions at various levels of preparation of the manuscript. While Dr. DB has carried out the research, Prof. PA has given his immense input in shaping the paper idea.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.