We often talk about India’s demographic dividend i.e. the bulge in working age population in the country. And there are good reasons for doing so. Today, our population is markedly younger than China’s. The average age of India’s population is 28 years, while in China, it is 37 years. In fact, approximately 37% of the population is between the ages of 15-35 years and it is projected that by 2050 India will be home to the largest number of working-age people in the world.
There is, however, a flipside to the demographic dividend which merits equal attention. India’s overall Total Fertility Rate (number of children born or likely to be born to a woman in her life time) declined to 2.2 in 2015-16, marginally above the replacement rate of 2.1. While the fertility rate is still fairly high in States like Bihar (3.41), Meghalaya (3.04) and Uttar Pradesh (2.74), it is already below the replacement rate in 23 States and Union Territories, including all the southern States.
Thus, even as we are striving to reach replacement levels in north India, ageing is already under way in many southern states, leaving the country with the potential twin burden of too many young people on the one hand and of rapidly rising numbers of old people, on the other.
It is therefore essential that we lay greater emphasis on creating an enabling environment in which we can ensure the health and well-being of senior citizens. There are, however, several challenges to contend with. Nearly 75% of the elderly population lives in rural areas and a substantive proportion are below the poverty line.
The Feminization of Ageing
We are also witnessing increasing “feminization of ageing” with women living longer than men. In fact, it is estimated that women constitute 55% of all older persons and they are often more vulnerable in terms of accessing medical care.
Further, the elderly population suffers from chronic, long-term diseases as well as acute ailments that are difficult to cure easily. Empirical studies reveal a high incidence of ailments and disabilities such as visual impairment or loss of eyesight, cataract, orthopedic and locomotor-related ailments, depression, Alzheimer’s disease and Parkinson’s disease, among others. Access to institutional support and specialized medical care is skewed, and largely concentrated in urban areas. While day care centers and old age homes also provide health care for the elderly, they too are mostly concentrated in urban settings.
Lack of Medical Facilities
The challenges are additionally compounded by the fact that India has around 0.9 hospital beds per 1,000 people, as against the World Health Organization recommended minimum of 3.5 beds per 1,000 people. We also have some way to go before achieving the ideal doctor: patient ratio of 1:1000.
Home-based healthcare can play a significant role, especially in this context. As a concept, homecare is gaining ground in India and the reasons for its growing popularity are both clinical and societal. It is generally more affordable with some estimates suggesting that it could be as much as 30% cheaper than hospital-based care as there are no infrastructure and overhead costs. Moreover, this model of healthcare delivery does not require a family member to take time off from work, resulting in additional savings.
Most importantly, perhaps, patient outcomes too are often better in homecare models, especially as a number of health conditions do not require hospitalization. A study by researchers at the University of California San Francisco compared the health and wellness parameters of older adults with dementia living at home versus those living in residential care facilities. They found that those who received home-based medical attention had a higher quality of life as compared to those who resided in nursing homes. This is perhaps not surprising because delivering health services in familiar settings (one’s own home) instead of hospitals can significantly increase the comfort level of patients.
China is Banking on Home Based Health Care for Elderly
Just last month, China passed a guideline for deepening the integration between medical and old age care by providing concentrated or home-based health services for the elderly who are unable to take care of themselves.
If India is to tap into the full potential of home health care, some key challenges will need to be addressed. Firstly, home-based health services require multiple stakeholders such as nursing agencies and medical suppliers, most of whom are currently small-scale and unorganized. Second, there is a shortage of accredited training institutions and absence of a structured training program. Third, there are high attrition rates among nurses due to the fear of exploitation in home settings as well as inadequate salaries.
There is therefore an acute need for setting standards for care delivery in the home and developing mechanisms for ensuring accountability of all those involved. We must also include geriatric care in the medical curriculum and provide formal training to nurses and paramedical staff on elderly care. There is much to be learnt from the experience of countries like Denmark and Finland where home care workers receive 1-3 years of formal training initially, with opportunities for additional training during the course of their careers.
Moreover, this industry can employ a large number of skilled patient attendants and caregivers from rural and remote areas with even a basic Class 12 qualification and reasonable communication skills. Another big added benefit of developing home health care would be the ability to boost the female labor force participation rate which at 24% is currently amongst the lowest in the world. Around the world, health providers delivering care in home settings are overwhelmingly women.
We must put in place systems for providing affordable and accessible health care today if we are to gear ourselves up for the elderly boom in the years to come.
Disclaimer: Views expressed are personal.
Urvashi Prasad is a Public Policy Specialist and Vedeika Shekhar is a Young Professional at NITI Aayog.
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