Care of the Elderly
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About the authors
HelpAge
HelpAge India is a national level voluntary organization working for the c
and care of disadvantaged elderly in India for the past 26 years. HelpAge has
implementing projects that provide health, economic and emotional s.
to the elderly besides direct intervention to provide relief to the eid>.
also undertakes Research and Strategic Department work to mainstre;
issues concerning ageing and aged in India. For this purpose HelpAge on ,
seminars, discussions,interactive sessions with all the stakeholders; cont
articles to various academic and other journals/magazines; publishes a j
and reader friendly booklets. It also compiles information on old age h:
and on the benefits and privileges given to elderly in the country.
Assisted by
Namrata Ranjan
Namrata Ranjan is Masters in Social Work, working as a Young Professional in
CAPART (Council for Advancement of People’s Action and Rural Technology).
She has been seconded toVHAI by CAPART and has been working as a Research
Associate for the Independent Commission on Development and Health in
India.
Community Health Cell
Library and Information Centre
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Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE - 560 034.
Phone : 553 15 18 / 552 53 72
e-mail : chc@sochara.org
Care of the Elderly
Independent Commission on Development and Health in India
New Delhi
Publisher
Alok Mukhopadhyay
Coordinator
Neepa Saha
Editor
Vijaya Ghose
Production Coordinator
Puja Sharma
Design & Pagelayout
Brajagopal Paul
Gaurav Paul
Production
Development Communications Unit
Printed at
VHAI Press
ISBN: 81-88973-71-8
©Voluntary Health Association of India, 2004
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z"
The Executive Director,VHAI
GS095
pOQ
Independent Commission on Development and Health in India
Alok Mukhopadhyay
Convenor
Chief Executive,Voluntary Health Association of India
R. Srinivasan
Former Secretary, Ministry of Health and Family Welfare, Government of India
Ashish Bose
Hony. Professor, Institute of Economics
Dr, Shanti Ghosh
Paediatrician and MCH Consultant
Dr. N. S. Deodhar
Consultant in Health Sciences, Services, Management and Research
Darshan Shankar
Founder-Director, Foundation for Revitalisation of Local Health Traditions,
Bangalore
Dr. H. Sudarshan
Chairman,Task Force on Health and Family Welfare, Government of Karnataka
G. R Dutta
Member. State Planning Board, Government of West Bengal
Rami Chhabra
Former Advisor, Ministry of Health and Family Welfare, Government of India.
Dr. Mira Shiva
Director, Women Health & Development and Rational Drug Policy,
Voluntary Health Association of India
Foreword
Voluntary Health Association of India facilitated setting up of the Independent
Commission on Health in India in 1995,renamed as the Independent Commission
on Development and Health in India, as a people’s initiative to assess the current
health and development status and facilitate the process of need based and
people-centric, sustainable development and health.Through analysis of existing
data and in-depth study the Commission, consisting of distinguished persons
from the health and development sectors, identifies the maladies affecting the
present health care system and development programmes and provides clear
recommendations for future action.
The first Report of the Commission was released in 1998 by the Prime Minister
and was also presented to the President of India. The Report was widely
distributed, discussed and debated in different fora, including the Parliament, the
Health and Family Welfare Ministry and the Planning Commission. In many ways
the report has influenced current thinking on various issues pf public health
including the National Health Policy and the National Population Policy.
The first Report was a summarized version of voluminous reports prepared by
the Commission over two long years of painstaking but rewarding process. Some
of the significant chapters were published as separate monographs.
The second Report of the Commission particularly addresses the issues of
Poverty Alleviation and Governance of Social Sector.This is particularly keeping in
mind the poor performance of the Nation in both these areas. Besides these core
areas ICDHI will also research on following areas of current concern:
I.
Revamping and Re-energizing of Primary Health Care.
2.
Private Sector in Health Care and Medical Ethics.
3.
Human Resource Development in Health Care..
4.
Health Sector reforms and external assistance for health.
5.
Role of Indian Systems of Medicine in strengthening health care practices.
6.
HIV/AIDS and Reproductive and Child Health.
This monograph focuses on the need to care for and support the elderly, given
the fact that the elderly population in India in 2001 was a whopping 71 million and
is projected to be 114 million by 2016. It is time we take stock of the health and
economic security provided to the senior citizens of the country.The monograph
poignantly brings out the change in status of the elderly in terms of their economic
and emotional dependence on the younger lot.The health concerns of the elderly
need to be adequately addressed and services provided for the same. Although
there are various schemes for the elderly, somehow the benefits do not reach the
targets, either due to lack of awareness or apathy of the service providers. The
monograph gives a well-laid out set of recommendations for the income, health
and emotional security of the elderly.
Alok Mukhopadhyay
Content
1.0 Introduction......................................................................................................... I
2.0 Demographic Trends........................................................................................... 3
3.0 Economic status of elderly in India................................................................... 5
3.1
Change in the Status: Economic and Emotional Dependence............. 5
4.0 Provisions for economic security of older person......................................... 7
4.1
Government schemes for poor elderly.................................................. 7
5.0 Health and Medical problems............................................................................ 9
6.0 Mental Health.................................................................................................... 12
7.0 Health Care Provisions.................................................................................... 14
8.0 Recomendation..................................................................................................16
8.1
Income Security....................................................................................... 16
8.2
Health Security........................................................................................ 16
8.3
Emotional Security.................................................................................. 17
[23 Introduction
Ageing is an inevitable process in the life of every human being; however, the
pace may vary from individual to individual. Most people tend to view ageing as
a problem, but these people lose sight of the fact that elderly represent a vast
reservoir of experience and maturity and could be used to the advantage of the
family, community and country. So, there is an urgent need to take a hard look
at how, the elderly themselves, and the society perceive them. However, all said
and done, one cannot deny the fact that like every other stage in life, old age also
presents its own peculiar challenges to human beings.
In old age, the need for economic, health and emotional wellbeing assume
special significance because of gradual reduction in abilities. Traditionally, family
provided these comforts for its ageing members, as it was based on the principle
of reciprocity among generations. These ties were reinforced by the economic
relations and social conventions. In contemporary world, these bases of family have
weakened due to lessening of dependence on family assets for economic sustenance;
prevalence of values of individualism and other such developments. Despite these
changes, family is still considered the mainstay of social support for the elderly in
India.Though the Indian state was never unmindful of the welfare of elderly and
this is reflected in the Constitution of India wherein, under article 41,“the State
shall, within the limits of its economic capacity and development, make effective
provision for securing the right to work, to education and to public assistance in
case of unemployment, OLD AGE, sickness and disablement and in other cases
of undeserved want”.This promise has been fulfilled to the extent that the later
governments were committed to labour welfare and made several provisions
for social security. But, the real challenge is to provide economic security to the
workers in the unorganized sector that constitute almost 90% of the workforce
and also those who live below poverty line.
\
The problem of economic security has not only compounded over the years for
following reasons, increasing longevity, increase in absolute number of elderly and
adoption of lop sided policies to pamper the governmental sector and making the
post retirement benefits almost unsustainable.Average life expectancy at the age
of 60 years has increased from 12.4 years in 1950 (Source.-Sharma,S.P. & Xenos, P.;Ageing in
India: Demographic Background and Analysis based on Census Material: Occasional paper No.2 1992; RGI,
New Delhi.) to
17 years in the year 2002 and expected to be 20.8 in the year 2050
(Source -World Population Ageing: 1950-2050. Dept of Economic and Social Affairs Population Division, United
Notions. New York-2002.) The number of plriprly has also increased from
19,61 million
in 1950 to 81.09 million in 2002 and expected to increase to 323.82 million by
the year 2050.The solutions to these problems should be found in the changed
context of shrinking family and government support to the elderly and increased
role to the market force'sS
The other related issue is that of health security of elderly. Here also the scenario
is more or less similar to that of income security.The government employees have
been provided health services under the CGHS scheme and ESI, but this covers only
a miniscule minority of elderly.Those at the bottom of the rung i.e.the people below
poverty line, just above it and those in the not so poor category, petty bourgeoisies
are all beyond the purview of any organized system of health care delivery. They
are at the mercy of private practitioners and the PHCs, CHCs and government
hospitals. Besides the pertinent questions of availability and accessibility; there are
the questions of affordability.This last question assumes significance in the changed
context of privatisation and liberalisation. Private sector has entered health care
delivery and insurance as a major player.These facilities may not be affordable to
most of the elderly people as their resources shrink with age. Insurance coverage
is restricted by age and other stipulations. So, there is the need to plan for future
keeping these factors in mind.
2
^01 Demographic Trends
Due to preoccupation with increasing population in India, most of us have not paid
attention to another silent demographic revolution the country, whose implications
will become pronounced in the next fifty years. Depending on the decline in the
fertility and mortality rate and increase in the expectation of life, this will lead to
increasing in the proportion of the elderly after a time lag.
According to the official projections of the Registrar General, India, in the year
2001 the elderly population is estimated to be 71 million, and I 14 million by the
year 2OI6(the year for which the ultimate projections were made).
Table I : Percentage share of person 60 years and above in the total population
by sex, India 1901-1991
Year
Total
Males
Females
1901
5.06
4.55
5.58
1911
5.22
4.81
5.70
1921
5.37
5.04
5.70
1931
5.09
4.85
5.34
1941
5.66
5.43
5.91
1951
5.43
5.21
5.66
1961
5.63
5.46
5.80
1971
5.97
5.94
5.99
1981
6.32
6.23
6.41
1991
6.70
6.69
6.71
(Source: Census Data 1991).
Table I reveals that the proportion of the old age in the population of India
increased from 5.1 % in 1901 to 6.7% in 1991. Proportion of Elderly males increased
from 4.55% to 6.69% as compared to 5.58% in 1901 to 6.71% elderly females in
the same period.
Table 2 shows that the percentage of people above 60+ years of age in 1991 is
highest in Kerala (8.8%) and lowest in Assam (5.2%) In seven states, the percentage
is higher than the percentage of 60+ age group population in India i.e. more than 60
percent.The Technical Group on Population projection estimated the percentage
of population of India and some of the major Indian State, for the years 2001,201 I,
and 2016.These figures reveal that the percentage of 60+ years of Population will
gradually increase, except in Assam where it will come down from 5.2 percent
to 4.0 percent in 2016. Kerala and Tamil Nadu will have more than 13% of their
population in the age group of 60+ years by 2016.
Table 2: State wise Distribution of Percentage of the Elderly Population
_______________________________________________________
India / states
1991
2001
2011
2016
India
6.7
6.7
7.6
8.3
Andhra Pradesh
6.7
7.4
9.3
10.5
Assam
5.2
4.6
4.0
4.0
Bihar
6.2
6.1
6.7
7.4
Gujarat
6.4
6.2
6.9
7.7
Haryana
7.7
7.0
6.8
7.5
Karnataka
6.9
7.1
8.6
9.8
Kerala
8.8
9.7
1 1.6
13.1
Madhya Pradesh
6.6
6.5
6.9
7.2
Maharastra
6.9
7.1
8.0
8.8
Orissa
7.1
7.3
8.3
9.0
Punjab
7.8
7.2
7.0
7.5
Rajasthan
6.1
6.4
7.2
7.6
Tamil Nadu
7.4
8.4
1 1.5
13.1
Uttar Pradesh
6.8
6.6
6.8
7.1
West Bengal
6.0
6.6
8.3
9.3
Source: Report of the Technical Group on Population Projection. August 1996;Ashish Bose, Population Profile
of the Elderly (60+ yrs.) in India, (under publication)
In order to devise effective policies and programmes for the elderly in the country
following facts should never be lost sight of:
(i)
78% of the aged population lives in rural areas and the rest 22% in the urban
areas.(National Sample Survey Organisation (NSSO) data).
(ii)
Feminisation of aged population:
(1991) 27.32 million 60+ women (48.2% of elderly) the UN estimate says
42.46 million in 2002 (52.36%).
(iii)
Percentage of elderly women in rural and urban areas:
77.77 % of elderly women were living in rural areas according to 1991
census 22.23 % of elderly women were living in urban areas.
(iv)
Percentage of literacy level (literates and illiterates):
In 1991 only 27.15% of elderly were literate (40.62% of males and 12.68%
of females).
(v)
Percentage of widows:
According to NSS 52nd Round of 1995-96,58% of the elderly women were
widows.
££] Economic States of Elderly in India
According to the Census 1991, there were 22.2 million elderly (60+) workers in
India comprising of 17.8 million males and 4.4 millions females.This implies that
39.1 % of the total 60+ population were workers.The male work force participation
rate was 60.5% while it was I 6.1% for the females.
There were more than a million in each of the following states: U.P. (4.3 million),
Bihar (2.3 million), Maharastra (2.2 million), M.P. (2.0 million),Andhra Pradesh (1.9
million),Tamil Nadu (1.7 million),West Bengal (1.3 million) Karnataka (1.2 million)
and Rajasthan (1.0 million).The elderly work force participation in some of these
states are as follows: U.P. (45.5%), Bihar (42.4%),Tamil Nadu (39.9%),West Bengal
(30.8%), Karnataka (37.3%) and Rajasthan (36.4%). Andra Pradesh has the highest
female work force participation rate (24.2%) among the elderly and West Bengal,
the lowest (6.5%).
The National sample survey (52nd Round, 1995-96) collected data on economic
dependence of the elderly. The all India picture is as follows: among the elderly rural
males, 48.5% claimed that they are not dependent on others, 18% were partially
dependent and 3 1.3% were fully dependent on others. In the case of elderly rural
females, 70.6 % were fully dependent on the others, 14.6% were partially dependent
and 12.1% said that they were not dependent on others at all.
The urban scenario has been slightly different from the rural scenario. Here, 5 1.5%
of the males claims that they were not dependent on others, 29.7% were fully
dependent I 6.9% were partially dependent In the case of urban females, 75.75%
were fully dependent on others. In West Bengal, which tops the list of dependency
of elderly in India, over 88% of the rural females and 85% of the urban females were
fully dependent on others.The economic dependency ratio among the females is
the lowest in rural areas of Himachal Pradesh were 48.7% of the women are fully
dependent on others. Himachal has the highest ratio of economic independence
(23.6%) among females in rural areas. The NSS data provides the details about the
category of persons who support the economically dependent elderly. In India as
a whole, children support 73.2% of the rural males, and 76.5% of the urban males
and grand-children support 4.8% of the rural males and 5.2% of the urban males. In
the case of elderly fernale, children support 69.9% of the rural females and 67.9%
of the urban females.The share of grand-children is 5.2% and 5.5%, respectively.
3.1 Change in the Status: Economic and Emotional
Dependence
As age advances, dependence on "others" be it adult, children, grandchildren
5
or relatives, increases and this is accompanied by compromise with dignity,
independence and participation's is clear from the data quoted above,most Indian
elderly work, well after the age of 60 years, but need less to emphasis the obvious
that their contribution to family declines as compared to their adult children.This,
at times, result in decline in status in the family.
This loss of status is more pronounced in middle class families, where the elderly
have been in the organized sector and retire at the mandatory age of 60. This
abrupt departure from the active and productive work creates a void in their
life, unless he/she had diverse interests and activities in the field of art, literature
science, sports, religion etc.The individual’s life style is also likely to be adversely
affected, owing to reduction in income and loss of the'position’.The pinch of these
changes is felt more by people who have good health and feel they can contribute
more to the society because of their expertise and knowledge.These people, in
most cases are unable to find employment due to what is termed as ‘ageism’ and
are unable to contribute meaningfully to the domestic responsibilities. Despite
awareness at all levels to harness the potential of the elderly population not much
has been done to explore this possibility.
Structure of the family and relationships have also undergone tremendous change
in most parts of the country. Inter-country and intra-country migration of the
young adult, lack of adjustment in multi-generation households has increased the
vulnerability of the aged. However, intergenerational bonding though weakened
has not been severed.This, at times, help in bridging the gap, if any, between the
parent's and grand parent’s.
6
EJU Provisions for Economic Security of
©OcSfBir Persons
In India, economic security in old age is considered of prime importance; it is
believed that if one is economically secure in the twilight years of ones life, then
other problems can be tackled with ease. This coupled with the labour welfare
policies of the government has resulted in many programmes and schemes to
ensure income security in old age. Some of which are listed below:
(a)
Civil Services scheme of the Central and the State government:
In 1998. there were 7.3 million civil services pensioners in India (IMF, 2001).
In 1998, the average pension to average wage for the civil service was 45.1
percent, and the pension outlays accounted for about a third of the wage
bill at the Central and 22% at the State Level (IMF, 2001) even though not
mandated.The main social security for the Civil Servants are non-contributory,
unfounded DB pension which is indexed for both prices and wages, and has
fairly generous commutation provisions( up to 40% of the pension benefit
can be taken in a lump-sum) and survivors’ benefits (called family pensions).
The DB pension schemes provide a maximum replacement rate of the 50 %
of the average salary during the last 10 months of the service.
(b)
Public sector enterprise:
This includes insurance companies. Reserve Bank of India, Public sector banks,
electricity boards,oil companies such as ONGC .industrial entities etc. which
have their own pension.
(c)
Voluntary Tax advantaged saving schemes:
These comprises of the Post Office Saving Bank schemes (constituting 10% of
GDP), Public Provident Fund (PPF) and the group annuities of Life Insurance
companies (these are currently regulated by the IRDA).
(Quoted from: Reforming Indio's Social Security by Mukul G. Asher, Professor, Public Policy Programme).
4. 7 Government Schemes for Poor Elderly
(a) Targeted Public distribution: a scheme of distribution of tier system
to house holds below poverty line (BPL) and above poverty line food grains
at high subsidized rate entitled to lOkgs of food grains schemes covers about
600 lakhs families. (Source: U.K. Singh Ministry of Finance Delhi).
(b) Annapurna: Under this scheme 10 kg of food grains per person per month
free of cost will be provided to indigent senior citizens. Initially this benefit
was admissible to those persons who were eligible for old age pension but
were not presently receiving the pension.
(c) Subsidized Insurance Schemes: The Govt, of India as well as several
state governments have launched a variety of subsidized Insurance scheme
for the benefit of the weaker section of the of the people through the Life
Insurance Corporation of India and General Insurance Corporation of India.
One such scheme introduced is a pension scheme administered through the
LIC called Jeevan Suraksha. Another such scheme introduced through GIC
is Jeevan Arogya. In August 2000, many of these schemes were discontinued
and replaced by a new scheme called Janshree. Under this scheme insurance
benefit has been raised to Rs.20000 for the natural death and Rs.25000 for
the partial disability.
(d)
Government of India has also introduced another Insurance scheme for the
benefit of agricultural worker called Khetihar Mazdoor BimaYojna on
18th May 2001.The following benefit are provided under this scheme:
i.
Lump sum payment of Rs.20000 on natural death.
ii.
Lum sum payment of Rs.50000 in case of death due to accident
iii.
Lump sum payment of Rs.50000 in case of permanent disability or Rs.25000
in case of partial disability due to accident
iv.
Rs. 100 to Rs. 1900 per month will be entitled for pension to the agricultural
worker.
On death after commencement of pension the family will be paid a lump
v.
sum amount ranging from Rs. 13000 to Rs.250000 depending on the entry
to the scheme.
vi.
The insured person has to pay a premium of Re. I per day or 365 per
annum.
(Source: HelpAge Indio, Research and Development Journal, Special Issue, vol. 8 No. I January 2002)
(e) Varistha Pension BimaYojna: It is a Government's subsidised pension
scheme announced for senior citizen aged 55 years and above, in the Union
Budget 2003-2004.The scheme is being launched to provide an annual return
of 9% per annum.
(f) Dada-Dadi bond: Central Government announced new Dada- Dadi Bond
from April 1,2004, which will be a new saving instrument for senior citizens.
Persons above the age of 60 will be eligible to subscribe to this bond, which
will carry a return higher than the market rate of interest.The income from
interest of this bond is exempted from income tax.
(Source www.niad.com/news-unihealth.html )
gZU Health and Medical Problems
In a developing country like India, the elderly people suffer from the dual medical
problems of both communicable as well as degenerative disease.The elderly are
highly vulnerable to infectious disease because of their decline in their immune
functions and atrophic change in various organs. The psychological changes in
the old age lead to impairment cough reflex, impairment circulation and tissue
perfusion.There is a deficient collagen synthesis and poor wound healing. Further
incidence of infection remains high because of poor nutrition and high intake of
immune suppressive drugs.
Joint pain and cough are the most common health problem among elderly. Other
remote diseases include blood pressure, heart disease, urinary problem and
diabetes.A major killer among elderly was discovered to be respiratory disorder
in the rural areas and disorder in the circulatory system in urban areas. Lack of
adequate nutrition was one of the contributory factors for the ill health of the
elderly. Moreover the diet taken by them was deficient in micro nutrients, like iron,
vitamin A, robofiavin calcium etc, deficiency ofVitaminA leads to poor vision, dry
skin, and weakened immunity.Antacids (containing aluminum) are avoided because
their interface with calcium may causeAlzheimer’s disease and other type of senility.
Low socio economic status has been found to be the cause of deficiency.
Among infectious diseases, pneumonia is 50 times more common in the elderly
than in adolescents and it accounts for half the deaths cause due to respiratory
diseases, excluding cancer. Asymptomatic bacteriuria affects 30% of the elderly
women and 7% of the elderly men.The common cause of urinary tract infection
in the elderly is the insertion of catheter and other instruments.
(Source www.india-seminar.com)
Table 3A Distribution of Old age death by system (60+) in rural India, 1993
(Top 5 causes)
Disorders of the respiratory system
Disorders of circulatory system
Other clear symptoms
Disorders of central nervous system
Fevers
33.7%
21.6%
18.1%
9.6%
6.6%
Table 3B Distribution of Old age deaths by the disease (60+) in rural India 1993
Bronchitis-Asthma
Heart Attack
Paralysis
Cancer
Tuberculosis of lungs
25.8%
13.2%
8.4%
7.1%
5.8%
(Source: Data-Office ofthe Registar General 1997, reference book Active Ageing in New Millenium by Abba
Cboudhary)
9
The main cause of death among the elderly population is Cardiovascular disorder
accounting for 1/3 mortality followed by the respiratory disorder (10% ) and the
infectious disease forming 10%, Neoplasm 6% and the balance for others diseases.
The distribution of the moralities, sex wise in urban areas is given below:
65-69years
70+
Cause of Death
Male
Female
Male
Female
Infectious and parasitic disease
13.2
9.6
9.3
6.5
Neoplasms
5.3
6.9
4.1
3.8
Endocrine nutritional and metabolic
4.9
6.5
4.1
4.5
diseases and immunity disorder
Disease of blood and blood forming organ
1.5
1.8
1.4
1.9
Mental disorder
0.2
0.1
0.1
0.1
Disease of the nervous system
1.9
2.3
1.9
1.9
Disease of the circulatory system
38.3
36.3
36.9
36.9
Disease of the respiratory system
8.2
7.1
9.7
10.2
Disease of the digestive system
5.1
3.5
3.2
2.4
Disease of genitourinary system
1.8
1.7
1.7
1.2
Disease of the skin and subcutaneous
0.2
0.3
0.2
0.2
27.3
and sense organs
tissues
System, signs and ill defined conditions
15.7
19.5
24.1
Injury and poisoning
3.5
3.3
2.9
2.6
Others causes
0.1
0.5
0.3
0.4
All causes
100.0
100.0
100.0
I...0
10
(Source: Health Information of lndia( 1996) Directorate General of Health Services MoH&FW, Govt of India,
Delhi.)
Table 5: Percentage Distribution of Major Diseases of Older Persons In Rural
Areas 1991-1994
Year Bronchitis Heart Paralysis Cancer T.B of Anemia Diabetes Malaria Typhoid
& Asthma attack
Lungs
1991 25.9
12.8
9.7
6.0
7.1
4.7
1.9
2.1
1.3
1992 11.8
1 1.8
9.9
6.0
7.3
4.2
1.6
-
1.6
1993 12.5
12.5
9.8
5.8
7.0
4.4
1.8
-
-
1994 13.7
13.7
10.4
7.6
6.1
4.0
2.2
2.3
-
(Source: Survey of Causes of Death (Rural) Registrar General of India, 1991)
These trends have been confirmed by some micro studies as well and two of
which are quoted below.The prevalence ofTB is higher among the elderly than
younger individuals. A study of 100 elderly people in Himachal Pradesh found that
most of the patients came from rural background. They were also smokers and
alcoholics. Endocarditis thus is the major factor in the elderly mortality. Besides
these common infections, the elderly also susceptible to gastrointestinal infections,
pressure sores, septic arthritis, septic anemia and meningitis, which calls for special
immunization programs. (Source ww indio- seminar.com)
Prevalence of Physical Problem among the institutionalized elderly were studied in
rural and urban setting, covering both the sexes, (study conducted by Dr.V.S. Natrajan
at Chennai). Though the eye problem were high among the rural and urban area and
in all age groups, joint pain and dizziness was higher in rural areas.The proportion
of the older persons with headache, asthma, indigestion and shivering were same in
the institutionalized and non-institutionalised elderly in both the sexes. Restlessness
and weight loss were more in urban areas. Another fact that came to light in this
study has been that health disorders in older person were found to have some
difference as far as institutionalized and those living with the families were concerned.
Cardiovascular problem were more in institutionalized females as compared to non
institutionalized female while it was reverse in the case of males. More institutionalized
females reported mental problems than males.
Table 6
Institutionalized
Non Institutionalized
System
Male
Female
Male
Cardio-vascular system
16.39
22.31
26.09
18.52
Respiratory system
32.78
33.10
34.78
25.92
Central nervous system
14.76
17.27
15.21
5.56
Endocrine
11.47
10.79
15.22
3.70
Genito-urinary
19.67
10.79
10.86
9.25
Nutritional
24.59
23.74
26.09
33.34
Locomotor
26.24
36.69
36.95
50.00
Gastro-intestinal Track
24.60
34.54
19.57
38.88
Psychiatry
18.03
17.27
21.74
29.63
Female
Another concern that has yet not been researched in India pertaining to the elderly is
the implication of HIV/AIDS.This dreaded disease is expected to hit the elderly directly
and indirectly. In other words, there could be many elderly infected with HIV and many
more whose adult children will be inflicted with HIV/AIDS. Some of them may even
die leaving their young children in the care of the elderly parents.The trauma resulting
from the loss of family members and the stigma of being effected by HIV /AIDS can
result in high level of exclusion, for older people. Besides, in advanced age they will be
expected to take care of their young grand children. Such cases have come to light
large numbers in Africa. (See website of HelpAge International for more details).
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Mental Health
Mental Health of the elderly is another important area in understanding their overall
health situation. Mental health concerns of the elderly include depression, delirium,
psychosis and dementia. Over 10% of India's elderly suffers from depression and
40-50% of elderly requires psychiatric or psychological intervention at some point
in their twilight years.The principal mental disorders of old age are depression
and dementia. Schizophrenia is another disorder found in the old age eg. paranoid
psychoses which begin in later life; substance abuse specially alcohol abuse and
abuse of prescribed medication; anxiety disorders - specially those that begin as a
result of loss of confidence or as a result of physical illness such as hip fractured.
Delirium is usually the result of infections, in the older people who are not properly
nourished and who have other physical disorder, or early cognitive impairment in
older people in the developing world.
Another dimension of mental health that has been neglected so far has been the
gender dimension. Following points will highlight the need to focus on this area:
(i)
Alzheimer’s is a disease of longevity and women outlive men and are more
likely to be the victims of dementia.
(ii)
Delirium is also common in women as they are extremely sensitive to
things
like anaesthesia, drug toxicity and infections.
Depression is a common condition among women: life time risk of depression
(iii)
in women is 25% as compared to 7-12% for men; 113 of the cases of depression
in women go untreated.
12
Magnitude of Health Problems
To appreciate the magnitude of health problems faced by the aged, following points
should be considered:
I.
The National Sample Survey (NSS) findings on the aspects of physical mobility
as well as chronic disease indicates that 44%-47% elderly males were physically
immobile as compared to 67%-68% females.
Table 7: Percentage Distribution Of Physically Immobile Elderly By
Age, Gender And Residence
Age
Male
Female
Total
Male
Urban
Female
60-64
22.71
19.93
21.30
19.10
18.07
18.59
65-69
20.88
19.88
20.37
24.66
19.83
22.34
70+
56.41
60.19
58.13
56.24
62.10
59.17
Rural
Total
Source: National Sample Survey, 1991
Table 8: Percentage Distribution ofType of Chronic Diseases among
___________ the Indian Elderly by the age and Residence__________
(A) Rural
Age Cough
60-64 35.6
65-69 33.8
60+
70+
34.37
33.69
(3) Urban
Age Cough
60-64 24.16
65-69 24.25
70+ 24.95
60+ 24.52
Piles
pain
3.37
2.98
3.25
33.35
Joints
Blood
46.07
48.50
46.96
46.65
Pressure
6.47
6.22
6.42
6.52
Piles
pain
3.65
3.80
3.58
3.58
Joints
38.37
38.70
39.16
38.79
Blood
Pressure
18.53
17.65
16.60
17.48
Heart
disease
3.26
3.53
3.74
4.33
Heart
disease
6.44
6.88
5.93
6.34
Urinary
Diabetes
problem
3.20
3.21
3.53
4.05
2.04
1.78
1.73
1.41
Urinary Diabetes
problem
3.20
3.10
5.23
4.02
5.65
5.62
4.76
5.27
(Source: Notional Sample Survey, 1991)
As can be seen from the table, the proportion of the aged persons with chronic
disease varied from 44.3% to 45.5%.This proportion holds true for almost all
states. With regard to the prevalence of the chronic disease among the elderly
in general, the problems of the joints (46.96%) followed by coughs and related
complaints (34.37%) were found to be prominent. However, there have been some
13
differences between rural and urban areas.
The ageing survey 1993 points out three major impairments amongst the elderly
viz, vision, hearing and walking.
Table 9: Percentage Distribution of Elderly According to Impairments
Age
60-64
65-69
70-74
75-79
80-84
85-90
90+
Vision
28.9
32.8
35.6
45.3
54.5
66.7
60.0
Hearing
7.8
8.9
12.0
19.8
31.2
33.3
66.7
Walking
1 1.9
15.7
19.9
29.7
44.2
43.3
73.3
Source:Ageing Survey 1993, reference books Active Ageing in New Millenium by
Abba Choudhary)
Health Care Provisions
Health security is one of the basic pre-requisites for an enjoyable life in old age.
There are many aspects of health security that need to be taken into account
to ensure health. First and foremost is the concern of healthy ageing.This most
important fact about ageing has been neglected by all concerned to their peril.
Quality of life in old age depends on many things, particularly, on ones life style. If
throughout life an individual has been sedentary, negligent about food and nutrition
then one cannot expect to be healthy when ageing. "Tomorrow’s elderly are today's
adults, and yesterday’s children.” That is why WHO emphasis a life- span approach
for the elderly. Here, health promotion at all ages comes before geriatric care.
The other aspects of health security are availability of geriatric health care and
resources to foot the medical bills.These aspects are widely debated by experts
and policy makers and many steps have been taken to implement schemes and
programmes for this. Many hospitals are running regular geriatric clinics for the
elderly. Many NGOs are running Mobile Medicare Units for them, besides these
specialised efforts elderly can avail medical facilities general hospitals etc.
To cover the medical expenses of the elderly there are some schemes run by
government and some by public sector and private sector insurance schemes.
Some of which are given below:
I.
Central or State Government based system includes Central Government
Health Schemes (CGHS) and Employees State Government scheme (ESIS),
which is estimated to cover 20 to 30 million population;
14
2.
The community based Universal Health Insurance Scheme was announced in
3.
The New India Assurance Company Ltd. is implementing this scheme. The
the union budget 2003-2004.
scheme offers health protection and easy access to good health services to
the disadvantaged sections. Under this scheme, a premium of Rs. I per day
for an individual, Rs. 1.50 per day for a family of five (including the first three
children ) and Rs. 2 per day for a family of seven (including the first 3 children
and dependent parents) will entitle eligibility to get re-imbursement of medical
expenses up to Rs.30,000 towards hospitalisation, an accident cover upto
Rs.25,000 and compensation due to loss of earning at the rate of Rs. 50 per day
up to maximum of 15 days after a waiting period of 3 days. For below poverty
line (BPL) families, the'government will contribute Rs. 100 per years towards
their annual premium.
4.
The scheme run by the member based NGO cover about 5% of the population.
It is estimated that 20 million employees may be covered by such reimbursement
arrangements. Under the Insurance of GIC, LIC, UTI covers 3.4 million.
Policies of Life Insurance Companies
(a)
Nav Prabhat
It is close-ended scheme for Senior Citizens between 50 and 70 years of age.
Disability benefits include partial disability and disability due to sickness. Sum
assured is Rs 15,000 to 20,000. Life insurance Corporation has other policies
includes Asha Deep and Jeevan Asha. Asha Deep, includes cancer, paralytic stroke,
renal failure, and coronary artery disease. In Jeevan Asha includes respiratory
system, lymphatic system etc. in 2% of sum insured is also available.
(b)
UTI’s Senior Citizen Plan.
This policy is akin to Bhavishya Arogya Policy.The insured gets life long cover after
a pre-determined retirement period.There is no pre-exiting exclusion and there
is no provision for the return of the amount on withdrawal from the scheme.
(c)
Jan Arogya
This policy was introduced primarily to meet the needs of poor people both
urban and rural. The policy is essentially a medi-claim policy with the reduced
sum of Rs 5000 only.
(Source: HelpAge Journal + Internet site, www.niad.com/news-unihealth.html)
15
[iir Recommendations
The above account highlights the urgent concerns of aged in India. In order to
address the issues of immediate concerns of elderly of today and make effective
plans for elderly of tomorrow following steps are highly recommended:
8.11ncome Security
I.
Reforms in Non-Contributory Pension System: It is estimated that 30% of
the elderly in India are living below poverty line and the same percentage just
above it.This segment of social needs care and support.To provide them with
a safety net it is essential that there be maximum coverage of this segment
of elderly under old age pension scheme; preferably universal coverage of
elderly women, tribal and dalits.A drive to enroll the physically disabled or
people over 80 years of age should be launched. There should be a system
of identification of the elderly which automatically enrolls all those over 60
years of age in the list and also periodically identifies all those who will be
included in it each year.
2.
The young-old should be given opportunities to take advantage of rural credit
schemes to open small ventures to support themselves and their families.
Encouragement should be given to them to form SHGs. In this case also
preference should be given to women, tribal and dalits.
3.
In this liberalized and globalised economy where everything has become
market-driven, government should ensure some basic minimum return on
savings and ensure effective regulatory regime for the private pension fund
managers.
16
4.
Facilities of redeployment to the elderly should be provided through special
training for the skill development.The reemployment should be either part
time or flexi time, with the view to keep the older person busy, economically
independent, avoiding unnecessarily straining their physical capacity.
8.2 Health Security
I.
Plan health care facilities for elderly based on the need as highlighted by various
national level surveys and provide appropriate services in the tertiary health
care system. Make special provision for geriatric clinics with the help of private
sector and NGOs that can supplement government efforts.
2.
Geriatrics should be included in the curriculum of medical and paramedical
students as a compulsory subject. Sensitisation of existing staff through
refresher courses etc. especially the PHC and CHC staff as they are the first
point of contact for any patient.
3.
Special attention should be paid to health of elderly women particularly their
mental health. Not only facilities should be provided for them in terms of
clinics etc but awareness should be raised with the help of NGOs for the
urgent need to consult medical specialist and not to trivialize the issue.
4.
Medical facilities should be accessible to the elderly, so improvement in
infrastructure is required urgently.The ideal situation would be geriatric wing
in each district level hospital in the country.
Given the fact of privatization of medical facilities especially the tertiary health
5.
care system, government should regulate the practitioners to provide special
concessions to the senior citizens not only for hospitalization but also for
treatment and pathological tests.
Younger people should be encouraged to take up medical insurance for the
6.
entire family including their elderly parents, so that they have some cover.
Insurance companies should also be urged to spread awareness about
usefulness of these policies and also redesign their policies to give maximum
benefit.
7.
,”he most important issue of healthy ageing that can save money by preventive
care should be made part of the curriculum in school and colleges; so as to
reiterate its importance in life.
Over the years, WHO has been taking action to improve the health care
8.
of the elderly.The principal focus ofWHO’s action has been on community
participation and family care. Promotion of traditional family ties has, therefore,
been emphasized instead of institutional care. In collaboration with its Members
State, the WHO Regional Office for South- EastAsia has been concentrating
its efforts in several areas of elderly care.These include:
•
Identification of the special needs of the elderly.
•
Creation of awareness among policy makers and people.
•
Supporting the formulation of appropriate National policies, strategies and
programs.
•
Establishment of institutions or centres of excellence for health care of
the elderly.
8.3 Emotional Security
I.
Changes in the structure and function of the family in the modern socio
economic context are inevitable. The fact of the matter is that family may
not be able to take the strain of taking care of elderly, so support should
be provided by the community to take care of the elderly. Efforts should be
made to develop better home care services, with workers/volunteers specially
trained to take care of elderly people.
2.
To reduce conflict in families especially the urban middle class, family counselling
centres should be opened to help members of the family reconcile their
differences.
3.
Special care should be taken while framing the laws that concern the family
17
relationships that interests of elderly are reconciled with that of the younger
members of the family.
4.
Special programmes should be devised for school and college students to
promote inter-generational bonding.
5.
Sensitization of enforcement agencies, medical staff to spot cases of elder
abuse and treat them appropriately. Law needs to be in place to deal with
cases of elder abuse just as the law on domestic violence.
6.
Loneliness and isolation from family and other loved ones are common for
the elderly. Death of spouse may leave the remaining partner without the
enthusiasm or capability to care for him or herself. Encouraging and supporting
these folks to attend the group or community meals, and find new friends can
make a big difference.
7.
Connecting our elderly people with the support or care of young children.
Young children and elderly people often seem to have a special magic
together.
8.
The capacities and skills of the elderly should be used for village development
activities eg. social workers, health educationists etc. The elderly people
services should be utilized in various activities of the community such as
manning child care centres, cultural clubs, vocational training etc. for which
they must be paid remuneration.
9.
Counseling is needed to mentally prepare the elderly people to gracefully
accept the old age.
10.
There should be priority for allotment of houses for the retiring employees
at subsidised costs, where were necessary.
18
References
I.
Aabha Chaudhary (ed.), Active Ageing in New Millennium
2.
HelpAge India, Research and Development Journal vol. 10, January 2004
3.
HelpAge India, Research and Development Journal, Second World Assembly
4.
Kumudini Dandekar.The Elderly in India, New Delhi, June 1996
5.
www.niaci.com/news-unihealth.html
6.
www.undp.org.in
7.
www.india-seminar.com
on Ageing, Special Issue vol.8, January 2002
The Independent Commission on Development and Health in India
The Independent Commission on Development and Health in India (ICDHI),formerly
known asThe Independent Commission on Health in India (ICHI), was formed in 1995,
facilitated by Voluntary Health Association of India. The commission, comprising of
distinguished people from the development and health sectors, aims at assessing the
development and health situation of the country through policy research and analysis,
in-depth surveys, focus group discussions, public hearings, round table conferences
with developmental workers, policy makers and people, particularly disadvantaged
community at large. By means of participatory process, the Commission seeks to
identify the maladies impending the development and progress of the country and
come out with clearly defined solution to the problems identified.The Commission
works closely with the Prime Minister’s Office, Ministry of Health & Family Welfare
and Planning Commission within the government,and reputed Research organizations,
Non-government organizations, Panchayati Raj Institutions at the grassroots as well
as other relevant forums .The first report of the Commission was released by the
Prime Minister and was presented to the President.The report was discussed in the
Parliamentary forum. ICDHI’s constant endeavour has been to facilitate the process
of need based and people-centric sustainable development.
The Independent
ISBN: 81-88973-71-8
Rs. 40.00
Commission on
Development &
Health in India
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