The study of elder healthcare and the various factors that it depends upon has been a difficult problem statement and although adult health and ageing is increasingly attracting a substantial amount of attention, most scholarship focuses on numbers and statistics and does not employ the language of policy analysis to better understand the healthcare issues of the elderly.
India, the world’s second most populous country, has experienced a dramatic demographic transition in the past 50 years, entailing almost a tripling of the population over the age of 60 years (i.e., the elderly). Of the 7.5% of the population who are elderly, two-thirds live in villages and nearly half are of poor socioeconomic status. Half of the Indian elderly are dependents, often due to widowhood, divorce, or separation, and a majority of the elderly are women (70%).
Of the minority of the elderly living alone, more are women than men. Thus, the majority of elderly reside in rural areas and are dependent upon their families. Nearly, 90% of the elderly in India are dependent on informal sectors such as agriculture, business, and wage work, and only 29% have pension and renting property as a source of income. Studies have shown that nearly 58% of the elderly women and 45% of the elderly men are dependent in rural areas, whereas in urban areas, it is 64% and 46%, respectively. A total of 73 % of elderly persons were illiterate and dependent primarily on agriculture. About 90 % of the elderly were from the unorganized sector, i.e., they have no regular source of income. Two-thirds of them were reported to be living below the poverty line, i.e., 66 % of older persons were in a vulnerable situation without adequate food, clothing, or shelter. The old-age dependency ratio increased from 10.9 % in 1961 to 13.1 % in 2001, as a whole.
As per the prevailing socially sanctioned roles for elderly in India, most of the time symptoms of illness are disregarded both by patient and family as part of the “normal aging process” or something “not serious”. Even if it is acknowledged as a problem, some choose to self-medicate or use home remedies. Alternative healing practices, especially religious healing, are still the first resort for many.
A study found that as many as 46.3 % of the study participants were unaware of the availability of any geriatric services near their residence and 96 % had never used any geriatric welfare service. When it comes to viewing elderly as a valid and contributing part of the society worthy of competent state policies, what is often forgotten is that, they make important contributions to the society not only via the formal workforce (primarily in agriculture), but also in raising grandchildren, volunteering, caring for the sick, resolving conflict and offering counsel, and translating experience, culture, and religious heritage.
On the double question of accessibility and affordability of healthcare by elderly it is imperative to highlight the various forms of vulnerabilities – vulnerabilities such as arising due to poverty, poor health, and weak social support. At a time when the traditional support system (family) for the elderly is decreasing – state policy must step up to combat such challenges. Some of the findings of the study conducted by the UNFPA in collaboration with Tata Institute of Social Sciences (TISS), Institute for Social and Economic Change (ISEC) and Institute of Economic Growth (IEG) on the issue are as follows: a) One fourth of the elderly population did not own any assets, b) 6 percent of the elderly population was living alone, c) Two fifth of the elderly have no personal income.
In addition to gender and marital status, religion, caste, education, economic independence, and sanitation have bearing on elderly health. A study in Maharashtra found that elderly in scheduled tribe/ scheduled caste (SC/ST) categories were 54% less likely and other backward classes (OBC) 35% less likely to seek treatment for existing ailments in Maharashtra compared to other castes.
Family and Care
The Indian elderly generation is caught between the decline in ‘traditional family values’ (that morally obligated the younger to take care of their elder) on the one hand and the absence of an adequate social security system, on the other. It has led to increased incidences of the elderly being abandoned as homeless by family members.
State provided facilities for day care centres and respite care are scarce and inaccessible for most. There is a sheer absence of any home based rehabilitation measures or benefits accorded by the state to families to address caregiver burdens. The decline of the joint family system, migration of youth to cities and increasing costs of healthcare are a few of the problems of the aged in India.
The Indian elderly generation is caught between the decline in ‘traditional family values’ (that morally obligated the younger to take care of their elder) and the absence of an adequate social security system.
The unconditional respect, power and authority that older people used to enjoy in rural extended traditional families are gradually being undermined in India in recent years. Indian Older women face a triple jeopardy: that of being old, of being women, and of being poor. Women live longer than men with more disabilities, as a result of demanding workloads, repeated child births, inadequate nutrition and limited access to healthcare.
Although broader trends of economic dependence are changing, kinship systems and social support still have strong bearing on access to healthcare among the elderly. More importantly – a strong link can be established between ownership of property and kin-based caregiving arrangements. Property-less elders have a relatively higher likelihood of residence in old-age homes, living alone, and being looked after by relations other than their children when widowed.
Older Indian women face a triple jeopardy: that of being old, of being women, and of being poor.
Given this variable provision of support, “discourses of neglect” may emerge, where in their everyday lives, the needs and problems of the elderly are invisible to those who offer them support in times of acute ill health.
Mental Health and Elderly
The most overlooked issue when it comes to the discourse on geriatric healthcare is mental health issues in the elderly. The most common psychiatric illness in the Indian elderly population are depression, dementia and anxiety disorders.
Even though India has four types of resources to address geriatric mental health issues: 1) state funded government psychiatric hospitals and nursing homes; 2) private psychiatric hospitals and nursing homes; 3) non-government organisations; and 4) the most important, informal sources- family as caregivers – Indian elderly mostly fall through the gaps in these safety net due to inadequate assessment or treatment – whether by state or family.
In an ever changing familial landscape there is a greater need for the state apparatus to aid the elderly. But a combination of factors including but not limited to – lack of awareness, inadequate training opportunities; inequitable distribution of health resources and virtual absence of chronic care disease models plague the geriatric landscape in India.
In terms of infrastructure, very few Indian hospitals have geriatric units and most elderly patients are treated in general medical/psychiatry wards. Public sector hospitals suffer from problems of inaccessibility, inequitable distribution, and lack of staff, drugs and equipment. The private sector on the other hand is largely unregulated with serious complaints regarding poor quality of care and unethical behaviour. The health insurance sector in India doesn’t cover mental illnesses; otherwise too, in general, less than 20 % of Indians have some form of health insurance. A large portion of the population is forced to bypass free public services to pay out-of-pocket in private institutions.
The existing social assistance programmes for the poor in India comprises of state and national pension schemes such as – Integrated Programme for Older Persons (IPOP), National Policy for the Health Care of the Elderly (NPHCE), Indira Gandhi National Old Age Pension Scheme (IGNOAPS), Annapurna Scheme and Maintenance and Welfare of Parents and Senior Citizens Act (MWPSC Act), 2007.
The central government came out with the National Policy for Older Persons in 1999 to promote the health and welfare of senior citizens in India. This policy aimed to encourage individuals to make provision for their own as well as their spouse’s old age. It also encouraged families to take care of their older family members. The policy aimed at enabling and supporting voluntary and non-governmental organizations to supplement the care provided by the family and provide care and protection to vulnerable elderly people.
This policy also aimed at outcomes such as – a) strengthening of primary health care system to enable it to meet the health care needs of older persons, b) Training and orientation to medical and paramedical personnel in health care of the elderly,c) Promotion of the concept of healthy ageing, d) Assistance to societies for production and distribution of material on geriatric care, e) Provision of separate queues and reservation of beds for elderly patients in hospitals, f) Extended coverage under the “Antyodaya Scheme” with emphasis on provision of food at subsidized rates.
The health insurance sector in India doesn’t cover mental illnesses; otherwise too, in general, less than 20 % of Indians have some form of health insurance.
The National Programme for Health Care of the Elderly (NPHCE) is an articulation of the International and national commitments of the Government as envisaged under the UN Convention on the Rights of Persons with Disabilities (UNCRPD), National Policy on Older Persons (NPOP) adopted by the Government of India in 1999 and Section 20 of “The Maintenance and Welfare of Parents and Senior Citizens Act, 2007” dealing with provisions for medical care of Senior Citizen.
Major objectives of the NPHCE were to provide long-term, accessible, affordable, dedicated, quality care services to the elderly and to promote active and healthy ageing, so that the elderly could contribute to the development of the nation as was the case with elderly worldwide. The aim was to converge with the National Health Mission (NHM) from sub-district to tertiary level. The strategies to be adopted were preventive, promotive, rehabilitative, capacity building and use of information and communication.
The Ministry of Social Justice and Empowerment, Govt. of India also constituted ‘National Council for Older Persons’ in May 1999. The policy stipulated that State Govt. will take affirmative action to provide facilities, concessions and relief to senior citizens for improving their quality of life and to ensure that the existing public services are user friendly and sensitive to older persons. It provided a comprehensive picture of various facilities and covered many areas like financial security, health care, shelter education, welfare, protection of life and property etc.
The Integrated Programme for Older Persons is a scheme that provides financial assistance up to 90 per cent of the project cost to non-governmental organizations. This money is used to establish and maintain old age homes, day care centres, mobile Medicare units and to provide non-institutional services to older persons. The scheme also works towards other needs of older persons such as reinforcing and strengthening the family, generation of awareness on related issues and facilitating productive ageing.
However most of the state policies have not translated into robust state facilities on the ground level. Some factors that have played a role in non-implementation of such policies are –
Non -availability of trained manpower, no concept of home-based care, competing priority with other health programmes, difficulty in establishing geriatric centres, especially in nodal medical colleges, lack of advocacy and research on geriatric issues, lack awareness of problems of the elderly among others.
Additionally some further barriers in the implementation of these polices are – First, there is a lack of knowledge about these schemes. Second, even if people are aware, they have problems accessing these schemes. It was reported in the study that 53% of the elderly find it difficult to access and utilize the social security schemes.
Third, there is a problem of inadequacy. If they are able to cross all the structural barriers, the money they get is not enough to support them. 79% of the respondents found the schemes are insufficient to meet their basic needs.
However most of the state policies have not translated into robust state facilities on the ground level.
In an ever evolving landscape of the deterioration of ‘traditional family systems and values’ in India, the need for institutional care cannot be underestimated. Institutionalisation in many ways is the last resort in cases of severe dependencies, and more and more families are becoming increasingly insufficient to care for a progressively more ill geriatric population.
It is happening and will continue to happen as a result of economic, social and cultural issues as well as health care burden. Therefore it is imperative to stress upon improving the state capacity for dispensing better elder healthcare in India and increasing focus on preventive measure rather than post illness healthcare.