The high cost of ageing

Evidence shows that health systems must be recast to accommodate the needs of chronic disease prevention

June 22, 2017 04:02 am | Updated 07:22 am IST

Disability is the umbrella term for impairments, activity limitations and participation restrictions. (Representational image)

Disability is the umbrella term for impairments, activity limitations and participation restrictions. (Representational image)

The National Health Policy (NHP), 2017, is long on banalities and short on specifics. In a somewhat glaring omission, little has been said about the rapid rise in the share of the old — i.e. 60 years or more — and associated morbidities, especially sharply rising non-communicable diseases (NCDs) and disabilities. In the context of declining family support and severely limited old-age income security, catastrophic consequences for destitutes afflicted with these conditions can’t be ruled out. Besides, continuing neglect and failure to anticipate these demographic and epidemiological shifts — from infectious diseases to NCDs — may result in enormously costlier policy challenges. An estimate provided for the 2014 World Economic Forum suggests that NCDs may cost as much as $4.3 trillion in productivity losses and health-care expenditure between 2012 and 2030, twice India’s annual GDP.

Detailed projections of the old in India by the United Nations Population Division (UN 2011) show that India’s population, ages 60 and older, will climb from 8% in 2010 to 19% in 2050. By mid-century, their number is expected to be 323 million.

Population dynamics and a rapidly changing age structure reflect the combined impact of increasing life expectancy and declining fertility. Life expectancy at birth in India climbed from 37 years in 1950 to 65 years in 2011, stemming from declines in infant mortality and survival at older ages due to public health improvements. The key question is whether longer lives have translated into healthier lives. Our evidence raises serious doubts.

Evidence from IHDS survey

Our analysis, based on the India Human Development Survey (IHDS) 2015, the only nation-wide panel survey covering the period 2005-2012, throws new light on these issues. A major advantage of the panel survey is that the same individuals are tracked over a period of seven years.

The prevalence of high blood pressure among the old almost doubled over the period 2005-12; that of heart disease rose 1.7 times; the prevalence of cancer rose 1.2 times; that of diabetes more than doubled, as also that of asthma; other NCDs rose more rapidly (i.e. by two and a half times).

A related question is whether multi-morbidity (i.e. co-occurrence of two or more NCDs) also rose over this period. Often multi-morbidities occur non-randomly or systematically. The prevalence of high blood pressure and heart disease rose more than twice while that of high blood pressure and diabetes nearly doubled.

Wealth quartiles were constructed to examine whether prevalence of NCDs varied across them and over time. Often it is asserted that the burden of NCDs is increasingly borne by less affluent sections. of the population. In other words, wealth and health deprivations have a larger overlap because of more sedentary life-styles, dietary shifts towards more fatty and processed foods, rising obesity, high rates of smoking and alcohol consumption, rural-urban migration and changing age structure. The burden of NCDs shifted from the most affluent to the least affluent over this period. In both the first (least wealthy) and fourth (wealthiest) quartiles, the prevalence rose sharply in most cases but in all the rises were faster among the least wealthy. The ratio of high blood pressure in the first quartile relative to the fourth rose from 0.36 in 2005 to 0.40 in 2012; that of heart disease rose from 0.31 to 0.38; that of diabetes from 0.23 to 0.34; and that of blood pressure and heart disease rose from 0.11 to 0.58. As NCDs are associated with a large majority of deaths among the old — about 93% of the total deaths among 70 years or more in 2013 — they are now more vulnerable to mortality risk. In fact, the least wealthy have become more susceptible to this risk.

By age 60, the major burdens of disability and death arise from age-related losses in hearing, seeing or moving, and NCDs (WHO, 2015). Thus co-occurrence of disability and NCDs poses a higher risk of mortality.

Assessing disability

Disability is the umbrella term for impairments, activity limitations and participation restrictions. An assessment of functioning in activities of daily living (ADLs) is one method widely used to assess disability in older persons. Disability is usually measured by a set of items on self-reported limitations with severity of disability ranked by the number of positively answered items. Disabilities in ADL show dependence of an individual on others, with need for assistance in daily life. The activities of feeding, dressing, bathing or showering, walking 1 km, hearing, transferring from bed and chair, normal vision, and continence are central to self-care and are called basic ADLs. The IHDS provides data on seven disabilities defined in this manner.

In select disabilities, there is a sharp rise with age and over time. Difficulty in walking was 1.7 times greater in the age group 70-plus years relative to 60-69 years in 2012. Over the period 2005-2012, overall prevalence rose 6.1 times. Difficulty in using toilet facilities was 2.3 times higher among the older group (70-plus years). Overall prevalence was five times higher in 2012. Difficulty in dressing was about 2.5 times higher in the older group. Overall prevalence jumped about five times between 2005-12. Hearing difficulty was just under twice as high among the older group in 2012, while the overall prevalence rose 4.7 times over this period.

To assess severity of disabilities, these are classified into counts of 1-4 and greater than 4. The proportion of old women was larger than that of males in both groups and years. At the aggregate level too, disabilities grew in both groups, especially in the group greater than 4. Thus both prevalence and severity of disabilities rose during 2005-2012.

As observed earlier, it is the co-occurrence of NCDs and disabilities that is more likely to be fatal. We find that in most cases there was an increase. Heart disease and disabilities (1-4) rose 1.3 times. Blood pressure and disabilities in this range rose 1.2 times, as also diabetes and disabilities. Blood pressure and heart disease and disabilities increased 1.4 times.

In brief, that the curse of old age has become worse is undeniable. Along with expansion of old age pension and health insurance, and public spending on programmes targeted to the health care of the old, careful attention must be given to reorient health systems to accommodate the needs of chronic disease prevention and control by enhancing the skills of health-care providers and equipping health-care facilities to provide services related to health promotion, risk detection, and risk reduction.

Veena S. Kulkarni is Associate Professor, Department of Criminology, Sociology, & Geography, Arkansas State University, U.S.; Vani S. Kulkarni is Lecturer, Department of Sociology, University of Pennsylvania, U.S.; and Raghav Gaiha is (Hon.) Professorial Fellow, Global Development Institute, University of Manchester, England

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