It is a challenge for policymakers, care providers and society as a whole.
Population ageing has emerged as the grand challenge of this century; for policymakers, care providers and society as a whole. A review of India's population census is insightful. In 1961, the population of the elderly was placed at 24 million; it increased exponentially to 43 million in 1981; 57 million in 1991; and about 77 million in 2001. The proportion of the elderly in the total population also rose from 5.63 per cent in 1961 to 6.58 per cent in 1991 and to 7.5 per cent in 2001. India has thus joined the rank of “Greying nations” with over seven per cent of its population in the 60-plus years segment. A United Nations report has predicted that India will have 198 million ‘Old' (60+) people in 2030 and 326 million in 2050. Currently, there could be around 100 million ‘senior citizens' in India.
Studies have shown that elderly people in India suffer a double-whammy effect; the combined burden of both communicable (usually infectious) and non-communicable (usually chronic and lifestyle related) diseases. This is compounded by an impairment of special sensory functions like vision and hearing that decline with advancing age. Thus, elders have a considerable burden of both infectious diseases like tuberculosis and chronic illnesses such as diabetes mellitus, ischemic heart disease, and cancer. Indeed, a survey of elder health in Kerala showed that over a third of all elders suffer from chronic diseases and have a medical consultation or admission necessitated by illness in each year. Notably, the majority prefer to use private health-care services, even though they are more expensive, service quality being an important reason for such a preference.
It is also clear that disability and frailty accompany aging, especially after the seventh decade. Thus 25-27 per cent of Indian elders have visual impairment; 12-14 per cent are hearing deficit; eight pre cent are immobile and confined to home or bed, this figure rising to 27 per cent after 80 years, women being more vulnerable. Falls are a common problem causing disability; with over half of all the elderly in some studies having suffered a fall with or without serious injuries like fractures and dislocations. While aging is not synonymous with disability, a large proportion of the Indian aged population is disabled, the severity of disablement increasing with age: 36 per cent in the young-old (60-64); 42 per cent in the middle-old (65-69); 51 per cent in the older-old (70-74) and 61 per cent in the oldest old (75 and above).
No safety net
The absence of a safety net for the elderly has exacerbated the problem. Traditionally, the joint family in India took care of its elderly. These traditional care arrangements have been lost in the context of rapid urbanisation and an exodus of people from rural to urban areas and from urban areas to foreign countries. In the absence of such community support in the form of kinsmen or the extended family, and an inability to continue to earn their living, the elderly are often rendered destitute, if not financially, from a pragmatic perspective. While these problems plague most traditional societies that are in transition, their rapidly enlarging scope and scale, demand and necessitate an urgent response from our policy makers.
The Government India, supported actively by civil society, unveiled its National Policy on Older Persons (NPOP) over 50 years after Independence. A comprehensive document covering every aspect of the elder's life, ambitious, with a clear cut action plan, it proposed a role for the State in the elder care: health, shelter, financial security and protection against abuse. It recognised the need for affirmative action favouring the elderly, viewing them as national resources, creating opportunities for their development. Training, empowerment and partnership with elderly were seen as important in providing equality and dignity to all groups of elderly. Unfortunately, a decade later, the NPOP awaits complete implementation in all States and Union Territories of India, much of its promise remaining unfulfilled, prompting the Government of India to seek its revision to suit contemporary needs.
Discussions among civil society groups and concerned senior citizens in the run up to a re-organised NPOP, reveal many consensus points for the future organisation of elder health care. There is little doubt that the care of the elder must remain vested within the family unit and based within the community the elder resides in. Incentives for families that care for their elders are necessary; as are the development of community health-care resources; doctors, nurses and paramedics specialised in elder health care; and rehabilitation facilities for those with disability. The importance of Government and civil society partnerships needs to be underscored here; as is regulation of such elder health-care services for quality and cost. While the focus is often on in-patient (hospitalisation) care, there is a clear need to develop other models relevant to the elder: out-patient care, day care, palliative care, rehabilitation care, respite care and step down care. Developing community level health-care worker pools that will both screen the elderly for risk factors, disease and disability; and provide simple home based interventions is necessary; as is tiered access for the elderly to a range of professionals: from generalist to specialist doctors. Most importantly, perhaps, those working in this area feel the need for unitary, sustainable and replicable models of screening and assessment: health checks that would address apart from routine risk factors like hypertension and diabetes, areas of potential disability: vision, hearing, falls, bone and joint, respiratory and cardiac disability; and neurodegenerative disorders — strokes, Parkinson's disease and that looming public health challenge; brain degeneration and dementia!
The five ‘A' test
A second area of concern for those engaged in this sector is that of healthcare costs. A survey in 2001 revealed that nearly two-thirds of elders live in rural areas; nearly half are women, out of whom over half are widows. Two-thirds of all elderly persons are illiterate and dependent on physical labour; 90 per cent existed in the unorganised sector with no regular source of income; one-third living below poverty line. In sum, the majority of Indian elders are in potentially vulnerable situations without adequate food, clothing, or shelter. Providing health care that passes the “Five ‘A' Test” (Availability, Affordability, Accessibility, Acceptability and Accountability) to such a large vulnerable group, is a challenge that has to be confronted. Insurance cover that is elder-sensitive is virtually non-existent; insurance premiums increase in an unsustainable manner with age and there is rampant age-discrimination in the health insurance sector. Further, pre-existing illnesses are usually not covered, making insurance policies unviable for the elder. Indeed, senior citizens point out that they pay far more for health insurance than their utilisation justifies; and that elders end up subsidising the care of younger citizens, who form the bulk of health insurance consumers. Government sponsored comprehensive cover for those living below poverty line, and in elderly and destitute homes is necessary; as is family based insurance cover that addresses comprehensively, the unique health care needs of the elder.
Most importantly, perhaps, is the need for sensitivity and sensibility in making these plans. The elder citizen is a national treasure; one who has contributed to both national growth and familial development. As they approach the autumn of their lives, they experience diminishing ability to generate income, increasing vulnerability to illness and disability, and increasing dependency on their families and communities. Rather than view this dependence as a burden to be endured, we must as a society embrace it whole-heartedly, as a pay back opportunity; to thank senior citizens for their many unconditional contributions. The organisation and delivery of elder health care must therefore be approached with enthusiasm, altruism and generosity. Mature health policy for the elder combined with a generous dose of pragmatism in organising, delivering and funding health care services is the need of the hour. World Alzheimer's Day has just passed — September 21, 2010, and we should be reminded about the challenge of population ageing; the looming burden of elder disability; and the need for a comprehensive and pragmatic National Policy for Older Persons.
Acknowledgements: Mr. K.R. Gangadharan (Chair), Prof. Indira Jaiprakash (Member), and other members of the sub-committee on Healthcare of the NPOP for their inputs.
(Dr. Ennapadam S. Krishnamoorthy is a senior consultant in Clinical Neurology and Neuropsychiatry and Honorary Secretary of the Voluntary Health Services (VHS) in Chennai.)