Deep creases mark the face of the frail, old man who carries a 25 kilogram suitcase on his head. With two overfilled shopping bags balancing on either arm he walks fast; in a hurry to unload his burden onto the car of the passengers who have alighted from the train at New Delhi’s railway station. He is a coolie – carrying luggage at the stations – earning between INR 50 to 80 (0.62€ to 1€) per load.
For the majority of the elderly in India, growing older does not offer respite from a life-time of work. Limited financial and social protection for people means that over 80% of the elderly in India work for as long as physically possible to meet their basic needs.
The elderly form 8% of India’s population. This translates to over a 100 million people above the age of 60 years. By 2050 the numbers of elderly are expected to increase to over 300 million people. For a low-middle income country, which is witnessing a rise in non-communicable diseases whilst struggling to assure basic healthcare, the status of India’s elderly is a challenge in terms of ensuring social and financial protection, providing health services, especially for the management of chronic lifelong conditions.
There is remarkable heterogeneity in the demographic, social, gender, economic and cultural characteristics of the elderly. Southern states such as Kerala and Tamil Nadu with a lower fertility rate are in the advanced stages of demographic transition. Approximately 70% of the elderly live in villages; 50% are poor and over 70% not literate, with manual labour being the only source of livelihood for many.
The 2001 Census highlighted the feminisation of the elderly population in India. For women, being female has meant a lifetime of discrimination at home and elsewhere which continues even in old age. Approximately 66% of elderly women are fully dependent on others; 32% do not own any assets of their own. In a largely patriarchal society, dependence, especially physical and financial dependence on family members may impact health seeking behaviour negatively, resulting in delay or denial in seeking care, as well as physical or emotional abuse of the dependent elderly member.
Financial constraints to meet healthcare expenses are one of the biggest concerns for the elderly and their caregivers. Households with the elderly spend approximately 13% of their consumption expenditure on healthcare; with those above the age of 65 spending 1.5 times as much on healthcare as those between the ages of 60-65 years. Medicines account for the biggest portion of health expenditure. India is one of the largest producers of affordable generic medicines in the world, yet, expenditure on medicines is high. Health infrastructure and services, including geriatric care are largely concentrated in urban areas, as are old age homes and much of the private, civil society initiatives towards elderly care. Rural areas also include remote locations with difficult terrain, be it on riverine islands or forest areas; limited mobility, difficult terrain, financial constraints and fewer health services further impede access to health for the elderly. .
Articles 41 and 47 of the Indian Constitution include provisions for the right to public assistance in old age and direct “the improvement of public health as among its (the State’s) primary duties”. India is a signatory to international agreements on the welfare of the elderly. In keeping with its constitutional mandate and commitments at a global level, policies for the welfare of the elderly were introduced in the 1990s. India’s first National Policy on Older Persons was introduced in 1999 by the Department of Social Justice & Empowerment. Early policies for senior citizens took a rights-based approach and presented a broad set of areas of intervention on social protection of the elderly. Healthcare and access to health were incorporated within these policies and the responsibility of care was largely entrusted with the family. Initiatives by the government for the elderly have traditionally focused on social protection in the form of pensions for those below the poverty line (BPL), a public distribution scheme for food for the BPL, as well as concessions and rebates for travel. In addition, State interventions took the form of funding to NGOs to operate old age centres and established government-run old age homes. In 2007 the Government introduced theMaintenance and Welfare of Parents and Senior Citizens Act 2007 – legally binding offspring to care for their parents and establishing tribunals to that effect. More recently, in the wake of the Shanghai Plan of Action 2002 and the Macau Outcome Document 2007 the government formulated the National Policy on Senior Citizens in 2011. Its recommendations retain familial involvement, bringing in, now, the involvement of the government and private sector towards creating an “inclusive, barrier-free and age-friendly society”.
What has the impact of these initiatives been so far? The 39th Standing Committee on the Implementation of Schemes for Welfare of Senior Citizens (February, 2014), encouraged the provision of separate queues for the elderly at all levels of public healthcare facilities, a move which, however well-intentioned, certainly does not address the health needs of the elderly. Priority access for vulnerable populations notwithstanding the health needs of the elderly needs to extend beyond designated queues at health facilities. In addition, the Standing Committeenoted that the implementation of National Policy on Senior Citizens has not yet taken place.
Challenges emerge in the form of limited research and information on the health needs of the elderly. The issues of implementation of policies and the capacity to bring about reforms are other concerns, as is bringing healthcare for the elderly on the list of priorities.
Ageing and care of the elderly is largely a familial responsibility in India. Multigenerational cohabitation in one household, colloquially termed as ‘joint family’ was a common social feature in India, and continues in some places. In the absence of comprehensive social security, this has traditionally served as a natural social protection mechanism with families collectively caring for the elderly. However, social structures are changing in the country; families, irrespective of economic status, struggle to cope with the cost of rising health care and limited recourse to quality, affordable services for their elderly As Praveen Aivalli notes in a recent reflection about the neglect of elderly in India on PLOS Blogs, “In a country where there is supposed to be a long tradition of respecting the elders (Matha Pitha Guru Deivam – an ancient Sanskrit hymn comparing parents and teachers to God), it is a pity that health services and social security systems for the elderly are failing badly”. But maybe this is exactly the problem: well-being of the elderly goes back to ‘respecting the elders’ – with care being a familial responsibility – both in Indian policy and society. This clearly no longer suffices. Families and individuals need support and resources to offer the best possible health and nutritional care to their elderly, if not the bare minimum.
NS Prashanth, from IPH Bangalore & EV 2010, provided some inputs for this piece.