A Kumar, J Srivastava, P Bhardwaj, P Gupta
A Kumar, J Srivastava, P Bhardwaj, P Gupta. Geriatrics age should be a boon not curse for our mothers. The Internet Journal of Geriatrics and Gerontology. 2008 Volume 4 Number 2.
Over decades health achievements have been made in the country to achieve health for all .Today India has 70 million of elderly population over 60 years of age current health policies do not address significantly to improve the health status of geriatrics population to significant level. It is currently estimated that adults over 60 years make up 8 per cent of India's population and by 2021 that number will be 137 million. India now has the second largest aged population in the world. The small-family norm means that fewer working, younger individuals are called upon to care for an increasing number of economically unproductive, elderly persons. Geriatrics differs from general medicine not in quality, but in the probability structures of diagnosis, presentation of illness and the need for an explicit determination to intervene. Older people need more investigations for comparable levels of diagnostic accuracy. For example, age-related impairment of immunity is associated with increasing lethality and reactivation of latent infections. In addition, the old are more prone to developing side effects to drugs. Though the educational and clinical issues in geriatrics in India are similar to those in developed nations, the large population and the lack of funds make it much more challenging.
“As we begin the twenty first century, population ageing is poised to emerge as a pre-eminent worldwide phenomenon. The confluence of lowered fertility and improved health and longevity has generated growing numbers and proportions of older population throughout most of the world.’ (An Ageing World: 2001). While on one hand, population ageing represents a human success story, on the other, the steady, sustained growth of older people poses myriad challenges to policy makers and societies all over the world.
The United Nations estimates put the number of those aged 60 plus at 600 million, i.e. 10% of the world population and this number is expected to go up by 2 billion by 2050. The Indian scenario of ageing population, brings to light that India’s population of just over one billion in the year 2000 continues to grow at about 1.5% per annum and is expected to exceed one and a half billion by mid century. According to the Census 2001, the number of older persons in India was 70.6 million, or 6.9% of the total population. It is projected that the number of older persons will be 94.8 million in 2011 (or 8.3%), and 143.7 million by 2021(or 10.7%). Further, 63% of the total elderly population is in age group of 60-69 years, 26% in age group of 70-79 years and 11% in age group of 80 years and above.
Trends in gender studies of the elderly reveal that the life expectancy of women is expected to remain higher. For the period 2006-2010, the life expectancy of female is 68.1 in comparison to 65.8 of males which is expected to rise to 72.3 for females as compared to 69.02 for males during the period 2011-2016. This indicates that the population of elderly women will account for a larger population as compared to their male counterparts in 60+ age bracket. Similarly, a closer look at the location demographics highlights that around 75% of older persons live in rural areas and 25% in urban areas.
With changing lifestyles the younger generation are migrating from not only rural to urban areas but from country to another as well; leading to increase in old age dependency ratio. The old age dependency ratio (number of old persons 60+ years) to the working age group (15-59 years) has increased from 9.8 per cent in 1981 to about 12.6 per cent in 2001. (Census of India, 2001)
While the existing support system of joint families, preponderance of physical activity, vegetarianism, and social and spiritual enrichment, all known to promote healthy ageing, are widely prevalent in India, with the increasing pace of population ageing, the health of older persons has been the focus of recent attention. Existing data indicate a significant morbidity among the aged, and considerable variations in morbidity exist with respect to gender, place of residence (rural vs. urban), and socioeconomic status. Further, the dual load of infections and degenerative diseases in older persons is the final cause of death.
The increase in life expectancy with better health care, nutritious food and socio-economic status, has led to the demographic transition which impacts the prosperity and
health of the people. This necessitates an exclusive health management system for the elderly to address their specific age-linked health problems like cataract related blindness, osteoporosis and fractures, osteoarthritis, hypertension, diabetes, coronary heart disease, stroke, heart failure, Alzheimer’s disease and other dementias, Parkinson’s disease, cancer, enlarged prostate and depression, etc. Further, the needs of older persons living in rural areas require special attention. This involves planning for post retirement socio-economic security through continued skill up-gradation, employment and participation in other creative and gainful activities.
Need for Addressing the Concerns of Older Women
Gender governs the structure of relationships through the life cycle, from birth to old age. Gender differences in the aging process reflect biological, economic, and social differences. It influences our access to resources and opportunities, and shapes our choices at every stage of life. While gendered experiences impact the health and well being of both women and men in their later years, women who enter their older years with a past or continuing experience of discrimination, violence and abuse often suffer unrelenting poverty and persistent health problems including chronic pain, depression, and disability.
Current status of women
Women comprise by far the greater number and proportion of older population in almost all societies; this disparity is increasing with advancing age. In India, while the sex ratio favours men at all ages, the trend reverses in favour of females above the age of 70 years with the number of women exceeding the number of men in this age group. Sex ratio in elderly population, which was 928 in the year 1996, is projected to become 1031 by the year 2016. More often than not, women are over burdened with cumulative inequalities throughout the life cycle from womb to tomb as a result of socio-cultural and economic discriminatory practices leading to a secondary status. Thus, a longer life span is directly correlated to greater morbidity and higher incidence of health related problems among the older women.
The emotional turmoil which a woman goes through, the sense of anxiety, fear, anger and desperation that she faces in her early years, take its toll during the later years of life if she manages to survive the reproductive years. On reaching menopause, she looks forward to the years of freedom from the responsibility of bearing and rearing children and freedom of movement but often she finds herself with the responsibility of taking care of grand children, older husband or in semi urban and rural areas, she has to struggle for her daily livelihood. The relation between poverty and ill health has been universally established. Poverty affects the older women in rural areas the most.
Studies have revealed that the most common chronic problems of older women are fever, cold and cough, asthma, respiratory infections, dysentery, visual impairment, cataract, hearing impairment, swollen feet and diabetes whereas the major diseases and disorders of older women are rheumatoid arthritis, osteoarthritis, osteoporosis, backache and muscular problems, hypertension, cardiovascular and pulmonary disease, nervous disorders, demential Alzheimer’s disease and depression. Common reproductive health problem are pruritis vulvae, vaginal discharge, dispareumia, incontinence, uterus prolapse, cervical and breast cancer. Anaemia, ulcer in mouth and intestines, constipation, diarrhoea are the other manifestations of prolonged under-nutrition. In addition there may be diseases directly related to their occupations or habits like chewing tobacco (as a pain killer or hunger suppressant) “
Policies and Programmes of the Indian Government
Across the globe, steps have been taken by various countries to provide social systems for the elderly and other disadvantaged groups. Such systems ensure that senior citizens are not deprived of their most basic needs when they lack the resources to fulfill them. A brief overview of the policies and programmes of the Indian government for the elderly is presented for a deeper understanding.
National Policy on Older Persons (NPOP)
Government of India (GoI) announced the National Policy on Older Persons in 1999 to reaffirm its commitment to ensure the well-being of the older persons in a holistic manner. The NPOP while promising to safeguard their interest in terms of financial security, health, legal, social and psychological security, also envisages a productive partnership with them in the process of development by creating opportunities for their gainful engagement and employment. The Policy also appreciates special needs of older persons and therefore lays emphasis on empowerment of community as well as individuals to adequately meet the challenges of the process of ageing. To fulfill these objectives the NPOP broadly provides for the following:
Financial security through coverage under Old Age Pension Scheme for poor and destitute older persons, better returns on earnings/savings of Government/Quasi-Government employees’ savings in Provid
2. Health Security: The NPOP recognizes special health needs of the older persons to be met through strengthening and reorienting the public health services at Primary Health Care level, creation of health facilities and implementing health insurance.
3. Recognizing Shelter as a basic human need, the NPOP provides for earmarking 10% of the houses/housing sites in urban as well as rural areas for older persons belonging to the lower income groups.
4. Education/information needs of older persons the NPOP provides for proactive role in ensuring the same by disseminating knowledge about preparation of Old Age. It is also emphasizes the need for schools to have programme on inter-generational bonding.
5. Welfare and Institutional Care:
6. Protection of Life and Property of Older Persons: Maintenance of elderly within family, resorting to the provisions of law whenever needed is required to be ensured.
7. Training of Human Resource to care for Older Persons: The Policy lays emphasis on need for trained personnel/care givers.
This policy highlights the plight of older persons and offers an array of state interventions. However, let us examine some of its shortcomings to keep these in view as learnings for future efforts of this nature:
1. The pension rates paid to older persons afford hardly any additional income or livelihood security but is merely a token payment to ward off extreme destitution
2. The policy statement relied on the figure of 33% of general population for an estimate of the proportion below poverty line among those above 60 years as well – this may be an understatement
3. As there is no mention of the financial implications of carrying out the commitments questions of financial capacity, capability and viability arise
4. The provision for maintenance of parents by children is not to provide income or old age security but to prevent destitution and cannot substitute state action for providing risk cover to older persons. Further, there is reluctance on part of the parents to go to court against children
5. A 39 member National Council for Older Persons was created to advise, provide feedback, lobby and address complaints but ministries specifically dealing with important aspects of ageing have not been represented in it
The challenge of implementing such a multi level and multi dimensional promise is therefore, enormous and requires coordination, leadership, strategizing, networking, advocacy and above all effective monitoring, feedback and continuous system improvement.
National Social Assistance Programme (NSAP)
The National Social Assistance Programme came into effect from 15th August, 1995 and is a social assistance programme for the poor households. The NSAP includes three benefits as its components:
The Indira Gandhi National Old Age Pension Scheme (IGNOAPS)
The Scheme covers older persons/destitutes having little or no regular means of subsistence from his/her own source of income or through financial support from family members or other sources. It covers older persons under Below Poverty Line and the government contributes Rs.200 (approximately $5) per month per beneficiary. In November 2007 it was rechristened Indira Gandhi National Policy on Older Persons (IGNPOP) and enlarged to include all persons above 65 years of age under BPL. The scheme currently covers 87 million old persons and the 2008-09 Union Budget has proposed an outlay of Rs.34 billion with the target of reaching 157 million beneficiaries.
Some of the public sector insurance companies provide life insurance coverage up to 75 years of age and many private insurance companies now have 55 years as the last entry age providing old age security to millions of elderly.
Old Age Social and Income Security (OASIS)
This ‘project’ put forth by the Ministry of Social Justice and Empowerment, GoI, has constituted an expert committee. The report of the committee recommends a pension system which can be used by individuals and enables them to attain old age security by making modest contribution during their working career.
Jan Arogya (People’s Health) of SEWA
This scheme by Self Employed Women’s Association, Ahmedabad caters to older women who work in the unorganised sector. The scheme allows payment of premium in lump sum after harvest time when they are in a position to make payments. Health insurance schemes such as this may be up scaled at the state and national level as well.
Annapurna Scheme covers all the other elderly below poverty line who are not covered under the NOAPS. Destitute senior citizens or 65 years of age or above who, though eligible for old age pension under the National Old Age Pension Scheme (NOAPS), are not getting the pension are covered under the Scheme. 10 kg of food grains per person per month is supplied free of cost under the scheme. In 2005-06 a total of 167,000 tonnes of grains were allocated under the scheme.
Reverse Mortgage System
The government has launched a Reverse Mortgage System for senior citizens to extract value out of their property and lead a hassle free life by securing a regular income as loan against their existing property – the loan may be taken in installments or a lump sum.