Insights into Editorial: Falling off the health-care radar
National Health Policy, 2017 (NHP, 2017) seeks to reach everyone in a comprehensive integrated way to move towards wellness. It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost.
The policy recognises the growing need for rehabilitative care for all geriatric illnesses and advocates the continuity of care across all levels. However, the National Health Policy, 2017, has failed to discuss anything substantive in relation to health problems particularly faced by the old-age population of the country.
With rising age, numerous physiological changes occur and the risk of chronic diseases rises. The co-occurrence of chronic diseases and disability elevates the risk of mortality. Recent report, “Caring for Our Elders: Early Responses, India Ageing Report – 2017 (UNFPA)”, complements the NHP by focussing on the vulnerability of the aged to NCDs, recent policy initiatives and the role of non-governmental organisations in building self-help groups and other community networks.
While all this is valuable, it fails to make a distinction between the aged in general and those suffering from chronic conditions. It matters as many suffering from chronic conditions and disabilities may find it harder to participate in such networks.
It is well-known fact that India enjoys a rich demographic dividend. The population between the age group of 18 and 35 years accounts for almost 65% of the total. This is considered to be one of the key drivers for India’s growth in the near future. While this is an important aspect, the story concerning our country’s old age citizens must not be neglected.
What are the weaknesses of our health system w.r.t elderly care?
- The health system is ill-equipped to deal with surging NCDs(Non Communicable diseases);
- The staffs are not well trained to treat/advise the aged suffering from dementia or ill-health, and for early diagnosis and management of conditions such as hypertension.
- The quality of medical care is abysmal
- Hospitalisation costs are exorbitant and impoverishing.
- Health insurance covers a fraction of medical expenses incurred.
However, many of these chronic conditions such as hypertension can be prevented or delayed by engaging in healthy behaviours. Physical activity and healthy diets can mitigate these conditions. Others could be managed effectively if detected early such as diabetes. Supportive families and community networks often make a significant difference.
Why is no of aged people who are suffering from NCDs increasing?
Based on the India Human Development Survey (IHDS) 2015, among aged males and females (over 60 years) ¸ the proportions of those suffering from NCDs nearly doubled during 2005-12, accounting for about a third of the respective populations in 2012. More females than males suffered from these diseases. The proportions were higher among those over 70, and these doubled in the age groups 60-70 years and over 70.
A vast majority of those with NCDs had access to medical advice and treatment and the proportion remained unchanged during 2005-12. A sharp deterioration in the quality of medical services, the proportions suffering from NCDs have shot up despite high access.
Access to government health insurance nearly doubled but remained low as barriers for the aged remain widespread such as fulfilling eligibility criteria, slow reimbursement and a lack of awareness of procedures. In any case, the proportion of medical expenses covered was meagre.
Loneliness poses serious health risks
Loneliness is a perceived isolation that manifests in the distressing feeling that accompanies discrepancies between one’s desired and actual social relationships. The link between loneliness and mortality is mediated by unhealthy behaviours and morbidity. The fact that loneliness predicts health outcomes even if health behaviours are unchanged suggests that loneliness alters physiology at a more fundamental level. Research shows that loneliness increases vascular resistance and diminishes immunity.
Shattering of the spousal bond in old age poses serious health risks. In 2005, old females with NCDs were twice as likely to live in single member households than the corresponding males. In 2012, while the females were two and a half times more likely to be living in single member households, the share of males rose more than moderately. In effect, old females with NCDs became much lonelier.
The widowed were much higher among the females in 2005. Both male and female proportions of those married doubled in 2012 but the latter remained larger. So if we look at households with 2-4 members, we find that the proportion of aged females with NCDs living in them was much higher than that of males in 2005, and both rose rapidly, especially the latter.
So it is arguable that family support more than compensated for the sharp rise in loneliness. An important point is that today, ‘women are increasingly filling other roles, which provides them with greater security in older age. But these shifts also limit the capacity of women and families to provide care for older people who need it’.
In addition to loneliness, a high risk factor for NCDs is daily consumption of alcohol, especially local beverages. Daily consumption of alcohol among the aged with NCDs rose more than twice over the period 2005-2012. Banning of liquor sales in a few States hasn’t helped because of strong resistance from vested interests including politicians and expansion of illicit sales.
Networking as support
Children often play an important role in elderly support with the caution that filial piety shows signs of diminishing. That social networks are effective in providing support to the aged is far from accepted as there are questions of size of a network, whether it is proximal or non-proximal and whether there is social harmony. If social networks are instrumental in bonding together in periods of personal crises, this could compensate for a lack of family support, e.g. widows living alone, and help alleviate morbidity.
The IHDS also provides data on inter-caste and village conflicts, with the proportion of those suffering from NCDs living in villages that experienced inter-caste or other conflicts more than doubling during 2005-2012. Lack of social harmony induces helplessness, disruption of medical supplies and network support.
The World Report on Ageing and Health 2015 (WHO) is emphatic about what is known as ageing in place, that is the ability of older people to live in their own home and community safely, independently, and comfortably, regardless of age, income or level of intrinsic capacity. Ageing in place can be further enhanced by creating age-friendly environments that enable mobility and allow them to engage in basic activities. This reinforces the case that solutions to those with chronic diseases lie within but also outside health systems.
Need of the hour
- From a policy perspective, health systems have to be configured to deal with not one NCD but multiple NCDs to manage them better.
- The impact of multi-morbidity on an old person’s capacity, health-care utilisation and the costs of care are significantly larger than the summed effects of each.
- Besides, the reconfigured medical system must be complemented by stronger family ties and social networks.
Indian population has approximately tripled during the last 50 years, but the number of elderly Indians (aged 60 plus) has increased by more than four times. In India, the population of elder persons will cross 18% figure. It is against this backdrop that one should realise the need to look into the existing policy regime dealing with care and maintenance of elderly people.