Insights into the Condition of Elderly in India

We no longer have what our previous generation had, which was an intergenerational living arrangement with many children in the same vicinity, if not house, to care for/share the care of the elderly. Yet, the ­Indian policy for the aged remains optimistic about the role of the family in providing necessary support to elders. Till quite recently, the research on ageing was centred around demographic changes, and the dependency ratio and activity status of elders. India’s Aged: Needs and Vulnerabilities breaks this conventional straitjacketed analysis of elders and is a significant contribution on the needs and vulnerabilities of the aged in India. As the title of the book suggests, the needs and vulnerabilities of the aged are fittingly addressed in various chapters on economic dependence, health and disability, healthcare cost, role of family in utilisation of healthcare and satisfaction of the elderly. The book is a collected volume of 10 research papers by academics working on various aspects of ageing and the aged in India.

Though the book is not divided into sections, for the ease of understanding, it can be broadly classified as addressing two sub-themes. The first part consists of five papers dealing with economic activity, dependency and household health spending. The second part deals with the role of family, living arrangements, well-being and satisfaction of the elderly. While setting the tone of the book in the introduction, Udaya S Mishra and S Irudaya Rajan have aptly identified two factors—individual identities and social and family factors—as critical in shaping the needs and vulnerabilities of the aged. These two factors remain the central point of inspection to understand the needs and vulnerabilities of the aged in subsequent chapters.

Declining fertility and longer life expectancy mean the number of older adults is growing faster than the number of children and there is a rapid increase in old-age ­dependency ratio. Generally, population ageing is associated with physical and economic dependency, and falling labour force participation and income. However, the paper by T R Dilip suggests that during 1983–2010 the work participation rate (WPR) of the elderly has substantially increased, leading to the decline in the old and inactive group to 9.3%. As a result, the contribution of ­the elderly to the household has also incre­ased manifold since 1983. While economic contribution by males has incre­ased, females are providing domestic support to the household.

The paper further argues that the presence of an older person in the household will put extra stress on existing resources, which will lead to a reduction in overall household and individual welfare. Further increase in the WPR of the elderly is also seen as a lack of social security and economic support to the elderly (Alam 2006: 140). Therefore, the study on economic contribution of the elderly should also look at health status and working conditions of the working elderly. It will give us a ­better interpretation of their WPR and well-being. Further, the dependency-led argument of ageing should be studied by rebalancing their economic and domestic contribution to the household.

Economic Dependency

Ageing comes with higher incidence of activities of daily living (ADL) and instrumental activities of daily living (IADL), leading to the specific requirement of long-term care. According to Building a Knowledge Base on Population Ageing in India (BKPAI) data for seven states of India around 3.7% of the elderly suffer from any ADL limitations, 34.7% from any chronic morbidity, 34.7% from any locomotor disability and 49.6% from any IADL limitations, which requires long-term care. In this context, the major problems of disability are vision, hearing, and mobility impairment (UNFPA 2013). Rajan and Anjana A, based on an interesting longitudinal study (Kerala Ageing Survey) of four rounds, show that disabi­lity rises with age. They argue that an older person was expected to live 15 years with disability in 2004, which rose to 17 years in 2010. The conditions are much worse for female elderly; their chances of life expectancy with disabilities are higher than their male counterparts.

Syam Prasad has done a detailed study of dependent elders among various subgroups to identify the most vulnerable group. This study shows that the most vulnerable are the urban elderly women, who are dependent on others for their basic needs. To further understand dependency, individual relative deprivation and group relative deprivation are analysed. The elderly from the households that are deprived within their social groups have a higher probability for being economically disadvantaged and dependent; however this varies among various socio-economic status (SES) categories. Individually deprived elderly persons are more likely to be weak and dependent across any SES identity.

Health Expenditure

By 2030, the elderly will bear nearly half of the total disease burden in India. The elderly are more exposed to non-communicable diseases and chronic diseases, especially to cardiovascular disease and chronic pulmonary disease, diabetes, and cancer, requiring multiple health visits to outpatient departments and for hospitalisation. In this context, the paper by Sanjay K Mohanty and Akanksha Srivastava provides estimates and projected cost of healthcare for 2026. They estimated an increase in inpatient cost by 148% and in outpatient cost by 67% over 10 years. This will have severe implications for older persons and households in the ­absence of weak pension and health ­insurance coverage along with already weak health centres in India, on meeting existing goals. Applying “need standardised distribution” of healthcare utilisation, William Joe points out the pro-rich bias in healthcare utilisation. Poor elderly with gre­ater needs are not utilising healthcare services.

From the existing debates, it needs to be noted that the health and well-being of the elderly can be achieved with the full coordination of family, society, and health institutions. However, ­increasing nuclear family living arrangements and female employment outside the home and high youth outmigration have created a severe challenge for the elderly, particularly in situations requiring long-term physical support (Carmichael and Charles 2003: 782; Viitanen 2005: 12; He Daifeng and McHenry 2013: 19–20, 24).

Living Arrangements and Family

In the case of India, it is mostly family members who are the primary financial and physical carers; approximately 90% of the elderly are receiving help from their family. Most of them live in intergenerational settings. Of the family members, mostly daughters-in-law provide care ­followed by spouse and son. Besides, we should not overlook the 5% elderly living alone and 12% living with their spouses. This group must be in desperate need of physical and financial support. It would have been interesting to have some papers on this group in this book.

Two very interesting papers by Joe and Shalini Rudra argue for a revitalisation of the role of the family in elderly caregiving and well-being. These studies have shown that good health status and utilisation of healthcare services are better for elderly living with family members, and more precisely with their spouse. Despite the limitations of self-rated health data, with careful analysis and examination of results (self-rated health given in the National Sample Survey Office rounds on morbidity and healthcare ­utilisation), Rudra argues that family is the most critical determinant of ­better self-rated health of the elderly. The elderly living with their children and spouse rated their health better than those living alone or with extended relatives across any SES group. These two papers present a strong case for various incentives to the families taking care of the elderly. It also establishes the role of health systems whereby the elderly from the eastern region are more likely to report poor health than the western region of India. Across regions, the elderly living with their family members are better off than those living alone.

However, there are other papers in the book that look critically at multigenerational living arrangements of elderly. There is no data on the experiences of elderly living in a multigenerational family, although, with the help of a hierarchal linear regression model the link between living arrangements and health was expl­ained by the contextual factors in the paper by Tannistha Samanta. The paper explains that the level of urbanisation and proportion of elderly in a district leads to better health outcomes of the elderly, which means access to better household sanitation and healthcare services are effective ­factors in reducing disease burdens of elderly, irrespective of their living arran­gement. Thus this paper establishes the crucial role of household wealth in ­explaining the link between living with family and the health of the elderly. In a nutshell, all these studies look to the critical role of the family, for the care and well-being of the elderly. A few of the contributions also shed doubts on the role of family, and consider other essential factors like wealth possession and employment. However, in the absence of data on these issues, they conclude with a strong case for social and economic support to the elderly and the families taking care of them.

The last chapter by Anil Kumar looks at a totally neglected theme in elderly research, that is, role and requirement of nutrition for elderly health. When we have child undernutrition at roughly around 40% (IIPS and ICF 2017: in ref. 7), then the ­elderly might very well be suffering from lifelong undernutrition; the consequences of which start to roll out in old age. In countries like India, where people grow old with lots of dietary restrictions, it becomes challenging to make them follow the required diet. It gets further complicated for the poor elderly, where the household relies on them for economic support.

In Conclusion

The best part of the book is that it addres­ses quite a large audience. Resear­chers need to note the innovative methods of data use despite limited data available on the subject in India. Since ageing was always taken as a problem of the global North and it was never assumed that ­India would face this problem, we do not have data on this issue. The available data are a by-product of household and health surveys with different motivations, such as consumption pattern, ­living standard, reproductive health or health expenditure, and provide limited information about the needs of the elderly. To fill this gap, ­elderly-focused studies should be funded and supported more.

Further, the authors of the papers in the book have also used innovative analytical tools to figure out individual- and ­social-level effects, forecasting of health expenses, etc, which can be a great learning tool for students of health economics. It is also relevant for policymakers as it informs the “vulnerabilities” and needs of the elderly for policy purposes. It is essential for non-academic readers in their 30s and 40s to understand the economic, physical, and personal support their elderly need from them, and the preparation of the same for themselves.

References

Alam, M (2006): Ageing in India: Socio-Economic and Health Dimensions, New Delhi: Academic Foundation Press.

Bravo, David and Esteban Puentes (2012): “Female Labour Force Participation and Informal Care of Adults: Evidence for a Middle-income Country,” www.econ.uchile.cl/SDT.

Carmichael, Fiona and Susan Charles (2003): “The Opportunity Costs of Informal Care: Does Gender Matter?” Journal of Health Economics, Vol 22, No 5, pp 781–803.

He, Daifeng and Peter McHenry (2013): “Does
Labour Force Participation Reduce Informal Caregiving?” https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2292700.

IIPS and ICF (2017): National Family Health Survey (NFHS-4), 2015–16: India, Mumbai: International Institute for Population Sciences.

UNFPA (2013): “Knowledge Base on Population Ageing in India: Report on the Status of Elderly in ­Selected States of India, 2011,” United Nations Population Fund, UN.

Viitanen, K Tarja (2005): “Informal Elderly Care and Female Labour Force Participation across Europe,” European Network of Economic Policy Research Institute, http://www.enepri.org.