A Narrative Review of National Programmes for theElderly in India: The Geriatric Care Policy needs tomainstream Aging in Development

Introduction

As India experiences the demographic transition characterized by rising life expectancy and a corresponding decrease in fertility the signs of an imminent aging society are emerging. As substantially large cohorts are now surviving to older ages, there is an increased need for elder care and support. Older adults are also requiring more assistance or care to manage their day-to-day activities. Due to recent sociological trends we tend to see nuclearization of family structure and the resultant decline of extended families, widowhood, singlehood or strained intergenerational relationships, an increasing number of elderly are living alone in India^1,2 . Because of these demographic shifts, lesser amount of traditional family-based care is now available to older adults in India^3,4. This picture is however not uniform across India since Indian States are experiencing different phases of the demographic transition and vary to a great extent in their cultural practices, social norms, and socio-political contexts. Though there is an increase in the proportion of working individuals currently thereby decreasing the dependency ratio, the day is not very far when we will see a rapid increase in the number of older adults and the associated concerns and needs for geriatric care, loneliness, emotional health and mental health issues will come to the fore⁵ . With this impending situation at the door, it is of utmost concern today to revisit the geriatric care conundrum and support an integrated policy for Geriatric Care to be formulated to this very end.

The decennial Census points out that India’s elderly population has now risen to 8.57% and in few states such as Goa and Kerala, the percentage of the elderly is quite higher than the national average at 11.20% and 12.55% respectively⁶ . An increase in the older population has led to an urgent need for elder care and support. Additionally, on account of the epidemiological transition, the prevalence of chronic disease has increased in the community, more so among older adults leading to a double burden of disease3 . This has led to increased sickness and disability among older adults necessitating increased long-term care and support needs, especially healthcare requirements⁷ . Additionally, older individuals are having increasing difficulty with carrying out activities of daily living (ADL) and instrumental activities of daily living (IADL). For instance, a recent study shows that care and assistance required for carrying out different tasks has increased significantly^3,8. Another important phenomenon of interest is the growing feminization of aging in India where we find that there are on an average 0.7% more women than men in the elderly age group⁹ , and this can be attributed to the differential mortality patterns, age at marriage and lifestyle patterns that exist between men and women¹⁰. Nearly, two-thirds of elderly women were widows whereas only 22% of the elderly men were widowers¹¹ and this is also possible due to the mortality trend as well as differential ages at marriage might have a significant role to explain this phenomenon.

Concerns of the Elderly

As demographic shifts in India are reducing the availability of familial support to India’s older adults^1-4 there is a simultaneous unavailability of younger family members to care for these older individuals owing to many demographic possibilities. Research has shown that traditional family-based care is also becoming less common than in the past in India¹². Firstly, fertility reductions have led to fewer children being available to care for older family members. Secondly, with increased education, migration for employment and better economic opportunities, emigration has become more common and acceptable^3,4 . This has made adult children leave co-residential homes through migration, usually from rural to urban areas, urban to urban or even abroad often leaving elderly dependents behind^13,14,3,4. What this trend demonstrates is not a decline in financial support from children since financial remittances tend to continue, but a weakening of the ties and physical absence, the very presence of which defined this support traditionally.

Therefore, it is important to explore how the institutions of society, family and healthcare adapt and cope with the demographic and health transition that challenge the care of the elderly^15,3. Increased requirement of care is however not free from financial risks. In the Indian context, receiving paid or formal care may not always be feasible for the large older adult population which has not had formal means of employment and thus denied social security upon retirement in large measure. Although, the care needs of older adults in India have increased due to several reasons, there is little evidence on the form and extent of care received by the elderly in this changing scenario. Few studies have looked at care requirements of older adults and the sources of care and support, however, they have been very localized in nature^16,17. Although literature points out that the dominant living arrangement for older adults is still the ‘family’ in India, it is not assessed whether the family will be able to care for and support older adults in this changing scenario and to what extent the care needs of older adults can be met through the family alone. In fact, several recent studies point out to the resilience of the family in supporting their elderly and even though adult children move away due to work or other obligations, there are certain familial arrangements made internally such that either one of the children or the daughterin-law or the daughter stays back to care for the older parents^3,4. It is also seen that in the changing demographic and socio-economic scenario and in the case of dwindling care from children and family, other forms of care and support can emerge such as from extended family, neighbours, community, and religious institutions due to the high level of bonding and community living that India espouses^3,4.

With globalization and modernization, opportunities abound for educational and economic development, more and more Indian adult children are migrating abroad in search of better employment, educational or economic opportunities,¹⁸ leaving ‘left-behind’ elderly to not only to manage themselves but also look after the property and other matters at home. The picture is not very uniform though and through explorations in Kerala and Goa, Ugargol & Bailey (2018) have researched the intergenerational care patterns and investigated how adult children who emigrate prepare either another sibling or their wives into staying at home for caregiving duties to their parents. Living arrangements of the elderly are also undergoing a change as the traditional joint family system in India is undergoing strain and possibly moving towards gradual disintegration, and the move towards nuclearization of families has different repercussions for the elderly parents^3,19. Financial support and economic security of the elderly is usually based on filial support from the family, savings, support from the extended family, and marginally the support from the State. Except for those older adults who had held formal work engagements prior are in line to receive some sort of retirement benefits and that leaves most informal workers without any social security in their post-active working period. With advancing age and reduction in labour force participation the dependence on the family and possibly the State is bound to increase. There is also a gender gradient to this eventuality, and we see that a greater number of women older adults are dependents compared to older adult men. The olde age dependency ratio is expected to climb in the coming years²⁰. To explain the gendered dimension of aging in India, one of the possible reasons for a large proportion of widows in the elderly age group could be the much prevalent practice of men getting married to women of a much younger age^21-23. Secondly, the average life expectancy of women is usually higher than that of men possibly contributing to the high dependency ratio among women. Among men who are economically dependent, more than 90% are living with one or more dependents, whereas only 65% of the elderly women are living with one or more dependents. The elderly face social issues as well including neglect, abuse, and exploitation. With dwindling financial resources in the household and nuclearization of families, the neglect of the elderly is becoming a larger concern and abuse is commonly seen in those elderly who are economically dependent on the family²⁴. The BKPAI Report (2011) also finds that 6 % of India’s older adults live alone and 15 % of them live with their spouses exclusively. We see a gradual trend towards increasing numbers of older adults living alone bereft of their family and gender plays a role too. The Situation Analysis of the Elderly in India (2011), highlighted that nearly 50 % of Indian older adults are dependents, often due to widowhood, divorce, or separation, and most of these elderly individuals are women (70 %) and 1 out of 10 elderly women lives alone. In the southern State of Tamil Nadu for example, it was observed that as high as 16.2 % of women lived alone²⁵.

Health Concerns of the Geriatric Population

The importance of health and wellbeing cannot be denied as it is one of the primordial necessities for day-to-day activities. The process of aging of India’s population is of concern with respect to the state of health^3,4,15 of its older adults. As this segment of population occupies more and more demographic space, the issues related to older adults deserve prominence among the issues concerning our society^3,4. India now has an increasingly aging population and the state of health of the older adults demands due attention. The proportion of older adults living without social security mechanisms and without access to health facilities is growing alarmingly in India^26,3 . Added to this, the older adults in India are known to suffer from the double disease burden of degenerative and infectious diseases^2,3. With modernization, older adults increasingly face barriers to good health status and ‘care’ from within the family on account of family nuclearization and increase in dependency^27,3,4.

If we simply consider disability as a good indicator of the overall health status among older populations as it results from cumulative damage created by chronic disease processes that affect humans throughout life and that usually manifests itself in older ages^28,29,3, it proves to be a facet worth exploring. Several theoretical measures have been put forth to explain different levels of physical disability^30,31; however, it is known that a very large majority of older adults suffer from diminished functional abilities in physical (eating, bathing, dressing, walking, climbing stairs, getting-up from a sitting position, etc.) as well as sensory (hearing and vision) health domains²⁶. Everyday self-maintenance activities (ADL and IADL) are considered prominent indicators of disability which require monitored assistance³². Impairment in everyday activities indicates cognitive and motor deficits to carry out work-a-day routine tasks. Health and well-being of older adults are thus intrinsically affected by the social and physical environment and presence of family support has been found to be an important factor affecting the health and ability of older adults in managing their daily activities^33,3.

Interestingly, the discourse around care for older adults in India can be traced to the global gerontological discourse, which pathologizes aging and attempts to rectify it by providing universal, technical solutions to older adults. This argument completely ignores the subjective articulation of needs by elderly in different socio-cultural locations and the capacity or willingness of family members and children to respond to those needs^34,3,4. The notion of care is thus limited to ‘maintaining’ older adults through the supply of food, clothing, residence and medical treatment of elders by their potential heirs. Care is thus recognized as a unidirectional flow of material supplies to older adults who seen as incapable of doing so and the reciprocal intentions and obligations that drive caregiving are not considered^34,3 let alone the emotional and social needs of older adults

Extensive familiarity with the medical needs and ailments of the elderly is essential for planning and implementation of any national of global policy related to encouraging healthy old age. Certain diseases are more common among elderly than among the youth and recent research indicates that hypertension, cataract, osteoarthritis, chronic obstructive pulmonary disease (COPD), ischemic heart disease, diabetes mellitus, benign prostatic hypertrophy, upper and lower gastrointestinal dysmotility (dyspepsia and constipation), and depression as the common presentable diseases among geriatric patients and account for as high as 85% of all the diagnosis among older adults³⁵. With the double burden of disease, even common infectious diseases tend to cause higher mortality and morbidity among geriatric patients due to weakening immune systems³⁵. Because of age-related physiological changes and weakening of host response, older adults are generally more prone to infectious diseases. Tuberculosis and chronic obstructive pulmonary disease (COPD) are emerging as diseases of concern among elderly and it is often difficult to recognise and report the symptoms early enough³⁶ and both tend to cause extensive morbidity and mortality^37,3.

Among non-communicable disease, diabetes is quite widespread among the elderly age group³⁸. Studies indicate that the age-adjusted rates among geriatric patients are much higher than expected with prevalence ranging between 13% and 16%^38-40. Since the early symptoms of diabetes such as polydipsia and polyphagia are usually not recognizable clearly in geriatric patients, other atypical symptoms that are noteworthy include confusion, falls, failure to thrive, neuropathy, coronary artery disease, visual symptoms, and hyperosmolar coma.

Apart from the traditionally recognized microvascular and macrovascular complications among elderly, we also need to consider rarer complications such as cognitive decline, physical disability, drug-induced hypoglycemia, falls, fractures, and geriatric syndrome³⁸. Hypertension is one of the most important treatable causes of mortality and morbidity among elderly^41,42. Musculoskeletal disorders, especially arthritis, are a major cause of disability and discomfort among elderly. The prevalence of arthritis is quite high with studies showing nearly 60% of the geriatric population being affected by it. They determine the quality of life and the ability to live independently. Their occurrence leads to unstable gait and falls that are the most common causes of elderly morbidity³⁵. The other factors that affect the ADL include sensory impairment, primarily visual and hearing impairment⁴³.

The most common causes for visual impairment among elderly are presbyopia, cataracts, age-related macular degeneration, primary open angle glaucoma, and diabetic retinopathy⁴⁴ . As the age advances, the cognitive functions of the elderly also get affected. Depression is quite common among geriatric population. Nearly, 15% of the hospitalized elderly have delirium, usually attributed to the physiological consequences of the medical condition. Disorders such as dementia usually caused by underlying non-reversible conditions such as Alzheimer’s and vascular trauma have a huge impact on ADL of the elderly and will increase the burden on caregiver³⁵.

The Policy Framework for Elder Care:

The formulation of the National Policy for Older Persons (NPOP) in India in 1999 was in response to the increasing number and proportion of older persons and their disadvantaged status in terms of general social, economic, and physical well-being. The demographic transition process has been accompanied by industrialisation, urbanisation, migration, and modernisation, resulting in changing values and lifestyles, which contest the traditional values regarding accommodation of the elderly within households. The special features of the elderly population in India are: (a) a majority (80 per cent) of the elderly live in the rural areas, thereby making service delivery a challenge; (b) feminisation of the elderly population (51 per cent of the elderly population would be women by the year 2016); (c) increase in the number of the oldest-old (persons above 80 years) and (d) a large proportion (30 per cent) of the elderly are living below the poverty line. A combination of all these features makes the elderly very vulnerable.

The Constitution of India mandates that the well-being of older persons should be ensured without any discrimination. Many suggestions have been made for designing policies and programmes to ensure equality among the elderly. The NPOP, announced in January 1999 had the primary objectives of encouraging individuals to make provision for their own as well as their spouse’s old age; encouraging families to take care of their older family members; and creating in the elderly persons an awareness of the need to develop themselves into independent citizens. The policy also aims at enabling and supporting non-governmental organisations to supplement the care provided by the family; providing care and protection to the vulnerable elderly; providing health care facilities to the elderly; promoting research and training facilities, and training geriatric care givers and organisers of services for the elderly⁴⁵.

The Ministry of Social Justice and Empowerment (MOSJE) coordinates the implementation of NPOP while many elements of the Policy are under the mandates of several other ministries. After about a decade of implementation of NPOP, the MOSJE set up a committee of experts to review implementation experience and suggest ways and means for improving the policy content and its implementation. The revised National Policy for Senior Citizens (NPSC)⁴⁶ recognizes that (a) elderly women need special attention, (b) rural poor need special attention and (c) factoring the advancements in medical technology and assistive into the revised policy. Specifically, broad categories of intervention include: Income security in old age, health care, safety and security, housing, productive aging, welfare, multigenerational bonding, media and protection during natural disasters and emergencies^3,4.

Past Successes Need Consolidation

While population aging is considered a success of public health policy, medical advancements, and socioeconomic development, it is now the time for provision of a comprehensive public health response catering to the needs and aspirations of the older people in India. While it is an arduous task to plan and provide a program for the elderly in India on account of the various geographic and regional differences, cultural and societal influences, and ethnic variations, it is important to consider all these variations in preparing a blueprint for the future. A policy should be able to enable those who wish to continue working to work while those who wish to retire should be able to retire with sufficient social security measures to fall back on. The ability to provision for income security and supporting economic sustainability along with ensuring good health and well-being are some of the balancing acts that policy makers are faced with in planning for the geriatric population in India.

There is a firstly a need to augment the ‘aging in place’ notion with practical provisions that support those who are caring for the elderly, the caregivers and recognize their contribution to effectuating ‘aging in place’ for senior citizens. Social campaigning and persistent advocacy to promote legislation, influence public policy, conduct research, and provide public education on a wide range of associated matters that are of concern to the geriatric population as well as their caregivers needs to be addressed^45,46,3.

Secondly, while it is good to note that a national policy for older persons has been instituted, the implementation of this policy framework must be monitored and based on demographic and social fabric inputs, successive changes and amendments need to be incorporated in time to keep the policy relevant and implementable. Thirdly, there is a need to rope in interest from the vast non-governmental sector as well as the private sector. Comprehensive geriatric care cannot be managed by the government alone and hence there is a dire need to augment capacity through the inclusion of ideas and services from public, private, and NGOs to understand and act appropriately.

Fourthly, we see a strong requirement that the caregivers be included as key stakeholders in the planning process and are recognised as a primary source of care and support for the geriatric population in India. Any program related to elderly in India currently views the family as the primary support for elder care in India. Apart from the pension scheme for elderly, specific programs and policies targeting the caregiver should be implemented including incentivising those who provide care to the elderly through tax subsidies or rebates, etc3 . Provisions such as incentivising caregivers, formation of social support network groups, and capacity building of caregivers will be of utmost value here. Creating awareness about aging and understanding the needs of the elderly by educating the community and family are necessary to prevent social isolation of the elderly which will help in their continued integration into the society and keep them relevant and able to lead life with dignity and respect.

Fifth, we need to redefine the roles of the Centre and States with respect to providing and covering for geriatric care. The existing preponderance to vertical programs even in case of geriatric care is proving to be not very effective at the community level. It is important for States to look at their demographic distribution and trends and prepared their individual plans for preparedness to provide geriatric care and the Centre can function as the facilitator and coordinator of such activities. We see a huge gap between urban and rural India with respect to provision and availability of care facilities for the elderly and these include institutional care facilities, day care facilities and medical care facilities. Most geriatric patients who live in the rural side need to be included and mainstreamed. Their needs should be catered to through the provision of community clinics, day care centres and institutional care facilities which are geared to adhere to the local needs, attitudes, cultural and social aspects of the location. Also, separate facilities for men and women may need to be conceived such that there is equitable distribution and provision of facilities irrespective of gender with an emphasis on ensuring women are made part of the planning process. India being a patriarchal society, unless the program gives special emphasis on women, their needs will be ignored. The bottom-top approach will help us to come up with programs and plans that are applicable and relevant to both urban and rural India. Geriatric hospitals and clinics are the need of the hour for greater focus on the diseases that are more common among the elderly^{45,46,47,48,3}.

Unless the government encourages research and recognises researchers working on aging, older adults and needs of geriatric patients, it is difficult to find new avenues and explorations that better understand the needs of the elderly and reciprocate their needs. As India undergoes the demographic transition, traditional means of surveys and communitybased research may will have to give way to nuanced ways of eliciting the true perceptions of the elderly and this will be a turning point in relating research and advancing policy making through grassroot connect.

We need to address several issues that arise as the implementation of the NPOP progresses. These are and include: (1) What is the extent of coordination among multi-sectoral partners as was envisaged in NPOP? (2) How have different stakeholders managed financial contributions within their respective mandates (3) What has been the role of the National Council of Senior Citizens (NCSC, 2012) - what powers were vested and exercised to contribute to achieving the objectives of NPOP? (4) Measures taken to provide income security including social pensions for vulnerable senior citizens (5) Is there a gender focus that provides protection for older women who possibly face socio-economic, gendered, cultural and administrative hurdles, etc. (6) Ensuring policy relevance through suitable amendments to sharpen policy focus as it addresses multiple issues within scarce resources^3,45,46,47.

This comprehensive review emphasizes the need to develop specific recommendations for mainstreaming of aging as a policy goal such that aging phenomenon in India is integrated into multi-sectoral policies and across all levels such that cross-cutting implications of aging can be addressed in totality. There is an increased need to improving societal understanding of aging, needs of the geriatric population and developing empathy for older adults through concerted efforts that aim to reduce ageism and bring about better acceptance of older persons into the community and workforce at large.