br The Millennium Development Goals

The Millennium Development Goals on health have expanded access to basic health interventions to millions of people in low-income and middle-income countries (LMICs). However, access alone will not be sufficient to meet the Sustainable Development Goals (SDGs) if health systems cannot provide high quality care—ie, care that ceramide improves health outcomes and provides value to people. Emerging data show that many LMIC health systems struggle to consistently provide good quality of care. Yet change is possible. Primary health-care facilities, which tend to reach the poorest segment of populations, are an important plank in the drive towards achieving the SDGs. In Nigeria, supporting primary health-care centres in rural areas with quality assessment, an action plan, and technical assistance in management resulted in significant improvements in adoption of quality practices.
Anna J Dare and colleagues (January, 2017) report renal failure deaths and their risk factors from two nationally representative mortality surveys among people aged 15–69 years in India for 2001–03 and 2010–13 as a part of the Million Death Study. We congratulate Dare and colleagues for bringing the very important public health issue of renal failure deaths, which is usually an unnoticed issue, to the forefront. We have some comments to offer.
Our Million Death Study data indicate that, between 2001 and 2013, mortality rates from renal failure increased significantly in India, especially in the 45–69 year age group (), and in the southern and eastern states. For each death, two of 400 trained physicians independently and anonymously examined field records, consisting of checklist questions and a half-page narrative in local language, following strict and consistent guidelines for coding renal failure and other deaths. The ICD-10 codes to define renal failure did not include calculi-related conditions, which may lead to urosepsis, or “other” genitourinary system deaths which are non-specific. The rising renal failure mortality rates do not reflect changes in coding, but rather suggest that the rising prevalence of diabetes in the country is the most probable reason for these increases, with marked generational effects; Indian adults born in the 1970s onward had twice the risk of dying from diabetes-associated renal failure as those born in the 1950s and 60s. To avert premature mortality and morbidity from renal failure, diabetes and other non-communicable diseases (NCDs) in India, agile shifts in the country\'s health policies and health system are required, as Pramod Guru and Sitanshu Sekhar Kar highlight. NCDs are now the leading cause of adult mortality in India, even though the absolute risk of death from all causes and from NCDs are both falling by about 1% per year at ages 45–69 years (). Although renal failure is a small proportion of the overall burden, the risk of death from this disorder is rising. Prevention and long-term treatment of NCDs is required. Given the wide geographic and demographic variation in the burden of adult deaths and renal failure deaths in India, and their upstream causes, NCD policies will be most effective if they support health interventions that can be targeted at the state and district level. A key area in India\'s response to NCDs will be better management of diabetes, which is a leading risk factor not only for renal failure, but also for cardiovascular diseases such as heart attack and stroke. Prevention, early diagnosis, and treatment can reduce or slow the development of diabetes-related complications, including renal failure. The relatively young median age at which Indians are dying from diabetes-associated renal failure (55 years) suggests that there is much room for improvement. A hallmark of optimal diabetes management is treatment with effective preventive medications. Even a modest degree of glycaemic and blood pressure control can yield substantial gains in preventing microvascular complications. These measures are simple and demonstrably cost-saving. However, since diabetes and renal disease are often insidious in onset, improved access to dialysis and renal transplantation will still be needed for the hundreds of thousands of Indians who will develop end-stage renal failure in the coming years despite preventative health policies.