In the past few decades, concerns about “population explosion” have given way to joy about a “demographic dividend”. The latter is expected to give a push to economic growth due to the lower dependency ratio which results from having a larger proportion of the population in the working-age group. The “Asian Tigers” — countries such as South Korea, Taiwan, Hong Kong and Singapore — as also China, have exemplified the benefits.
The larger youth population is also expected to give an impetus to innovation and entrepreneurship. Not surprisingly, then, the young are in focus, with many programmes to facilitate their education, entrepreneurship, sports training, etc., but also well-being. This is as it must be, not just from an economic viewpoint, but especially from the perspective of health. Poor health, like inadequate education, could well nullify the demographic advantage. Of concern is data from the latest National Family Health Survey (NFHS)-5, which indicates that while much progress has been made, the metrics for infant and child health continue to be dismal, with some being even lower than what they were five years ago.
Yet, even as we pay attention to the young, there is both need and benefit in also looking at the other end of the spectrum. Life expectancy in India has risen from 50 (1970-75) to 70 years (2014-18); as a result, the number of elders (those over 60 years) is already 137 million, and expected to increase by 40% to 195 million in 2031, and 300 million by 2050. While one perspective would look at them as dependents (and, therefore, a drag on the economy), a rather different view would look at them as a potential asset: a massive resource of experienced, knowledgeable people. Converting them from dependents to productive members of society depends on two primary factors: their health and their capabilities.
Changing health-care needs
Generally, the elderly population needs more medical attention of a diverse range. As per the first ever Longitudinal Ageing Study in India (LASI), 11% of the elderly suffer from at least one form of impairment (locomotor, mental, visual and hearing). It is estimated that 58 lakh Indians die from noncommunicable diseases (NCDs) in India annually, and cardiovascular disease (CVD) prevalence is estimated to be 34% amongst 60-74 yearolds, rising to 37% in those above 75 years. As we move to a demographic where the growth rate of elders far exceeds that of the young, perhaps the biggest challenge that the country would face is to provide a range of quality, affordable, and accessible health and care services to the elderly. They require an array of specialised medical services at home including tele or home consultations, physiotherapy and rehabilitation services, mental health counselling and treatment, as well as pharmaceutical and diagnostic services. These needs are particularly evident now, with elders being advised to stay indoor as a precaution against the novel coronavirus epidemic.
As per the 2016 Healthcare Access and Quality Index (HAQ), India improved its HAQ score from 24.7 in 1990 to 41.2 in 2016. However, we still are significantly below the global average of 54 points, ranking at the spot of 145 out of 195 countries. The low HAQ worsens even further in smaller cities and rural areas where basic quality health-care services are very inadequate. Factors such as familial neglect, low education levels, socio-cultural beliefs and stigma, low trust on institutionalised health-care services and affordability exacerbate the situation for the elders. Inequity in health-care access compounds the problems for the elderly, who are already, physically, financially and at times psychologically restricted in understanding, responding to, and seeking medical care for various ailments. Consequently, most of them live their years in neglect.
Health care of the elderly has, sadly, been greatly neglected. An overwhelming proportion of the elders are from the lower socio-economic strata (including many who are destitute). They are unable to afford the cost of health care and slip into ever poorer health. The vicious cycle of poor health and unaffordable health costs is further accelerated by their inability to earn a livelihood. As a result, not only are they economically unproductive but are dependent on support from family or others. This, and poor physical health, adds to their mental and emotional problems. The Government does have schemes that cover the elderly and seeks to take care of these issues, but they are completely inadequate.
Despite Ayushman Bharat, the Government’s health insurance scheme for the deprived, and private health insurance, a NITIAayog report indicates that 400 million Indians do not have any financial cover for health expenses. One can be sure that a very large number of elders are among the uncovered. Both the Centre and States have pension schemes for the elders, but these provide but a pittance — as low as ₹350 to ₹400 a month in some States. Even this is not universal.
A 2007 law requires States to ensure earmarked facilities for elders in every district hospital, headed by a doctor with experience in geriatric care. Yet, a status report filed by the Government in the Supreme Court of India in 2019 stated that 16 States and Union Territories (‘of 35’) did not have a single ward/bed dedicated to elders.
Opportunities in challenges
Given the range of diverse challenges, can India take care of its aging population? The success of the COVID-19 vaccination strategy gives hope: a seniors-first approach led to over 73% of elderly population receiving at least one dose and around 40% being doubly vaccinated by October 2021.
Considering the demographic trends, India should reimagine its entire health-care policy for the next few decades, with an elderly prioritised approach. As senior citizens require the most diverse array of health-care services, the creation of adequate services for them will benefit all other age-groups. Apart from legislating pro-elderly health care and insurance policies, India needs to aggressively take certain measures, while finding opportunities amidst this challenge.
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India needs to rapidly increase its public health-care spending, and invest heavily in the creation of well-equipped and staffed medical care facilities and home health-care and rehabilitation services.
Presently, India has a major deficit in infrastructure and skilled medical care resources, with 1.3 hospital beds, 0.65 physicians, and 1.3 nurses for every 1,000 people. Over the next decade, we have the potential to add more than 3 million beds, 1.54 million doctors and 2.4 million nurses. We need to accelerate implementation of programmes such as the National Programme for Health Care of the Elderly (NPHCE). The Ayushman Bharat and PM-JAY ecosystems need to be further expanded and similar, special health-care coverage schemes and services need to be created for senior citizens from the lower economic strata. The National Digital Health Mission has tremendous potential to expand medical consultations into the interiors of the country. However, this requires a digital literacy campaign for senior citizens.
These essential steps will help to convert elders into a massive resource for socio-cultural and economic development, giving an altogether different perspective to “demographic dividend”. After all, the proof of a truly evolved and caring nation lies in the way it not only nurtures its young but also how it cares for its aging population.
Kiran Karnik is Chairperson, HelpAge India and an author. His latest book is D ecisive Decade: India 2030: Gazelle or Hippo